Professionalism in medicine: the new authority.

For Mrs. Jones, this Monday morning is very different than any in the past.

She usually gets up around 7 a.m., but today she is up at 5:30 a.m. She is about to leave for the hospital to have breast surgery because she recently received the terrible news that she has cancer.

She arrived at this point in her life after her family doctor, whom she has known for many years and trusts completely, ordered a mammogram three weeks ago. The mammogram was read by a radiologist she never met, yet she doesn't challenge the diagnosis because she trusts the judgment of her family doctor.

She was referred to a surgeon she never heard of to have a steriotactic needle biopsy. A pathologist she doesn't know read the biopsy--she's not even sure what a pathologist does--yet the pathologist's diagnosis of cancer changed her life.

She comes to our hospital today trusting that the surgeon, the hospital and its staff are competent. She allows herself to be put to sleep by an anesthesiologist she met only this morning, and places her life in the hands of people she has only known for a little over an hour.

This scenario is played out every day in the modern health care system; it is a system built on layers of trust that seem to transcend human nature. How is it that we have developed this trust and on what authority are we relying on that provide our patients this level of trust? In other words, what is the professional authority that affords us the status we have attained in the health care system of today?

Our current reality

In the past, the professional authority of medicine was based on acquiring skills necessary to provide health care. In his book, The Social Transformation of American Medicine, Paul Starr shows how medicine struggled to create and confer professional authority.

Starr shows how we validated our professional authority by processes such as standardization of medical education, licensure, and board certification over the last 200 years. Our authority was further based on the fact that the lay public had very limited access to information and relied on the professional for appropriate recommendations.

For years this authority gave the lay public enough assurance that their health care provider had acquired and retained the knowledge and training to advise them on the best course of action for their condition.

Despite a fairly rigid process that developed to confer this authority to our profession, we still see an unacceptable degree of outcome variation involving both physician and hospital care. This should not surprise us because a natural outcome of strong professional authority is autonomy, and autonomy creates variation--how can one be autonomous, yet be just like everyone else?

The health care system in America is the shining example of this great variation in the delivery of care. Autonomy transcends all levels of the American health care system. From the individual provider to the largest integrated system, we all believe in our autonomy over how health care is delivered.

Autonomy also explains the wide variation in the delivery of health care that we see in the U.S. Examples include cardiac surgery rates or C-Section rates that seem to vary almost independently of patient demographics but actually tend to be more directly related to provider demographics across the nation.

This variation is the outcome of a system driven not by the patients but by the physicians and hospitals that deliver the care. Not only does this bring into question the overall quality of this system, but we also realize that any attempt at controlling costs and managing resources within this system is fanciful at best.

What is changing?

The old professional authority that relied on education, licensing and training is slowly and steadily giving way to a new basis of professional authority. The evolution of a new age of consumerism in the American health care system is driving a change in what defines our professional authority, and the emerging authority is slowly and surely being focused on our ability to validate our performance both individually and collectively.

The unfortunate reality for us in health care is that this is happening to us and not because of us. We find ourselves scrambling to find out where we fall in the latest Internet site that lists the "best doctors."

What is even worse is that most of these sites are making those determinations based on billing data that, even in the best of circumstances, are not always accurate and are driven by coding rules and billing procedures that are often not completely understood.

Nonetheless, it is occurring and it will only become more pervasive as the health care consumer becomes more educated, has easier access to information and begins to rely on these measures of performance to pick their health care providers.

It is incumbent on us to meet this challenge and be leaders in this process. If we do not take the opportunity to define what our new legitimate authority is, it will be defined for us.

Consumerism, performance information, marketing and a shrinking world present new and daunting challenges for health care providers. The risk of losing patients for elective procedures to other providers that may be even thousands of miles away is not futuristic; it is happening in many communities today.

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A recent example of this trend was found in the March 25th, 2004 Advisory Board Company publication "iHealthBeat" from a Wall Street Journal report that 28 large employers such as Sprint, Lowe's, and BellSouth covering more than two million employees and their dependents, is developing health care scorecards to help employees choose doctors and hospitals based on quality and cost. They will use claims data to evaluate how doctors compare to evidence-based quality standards.

As this information becomes more available, it is easy to see that our success will depend on performance and how we validate that performance. This creates a significant challenge but also provides an excellent opportunity.

The challenge is to create a culture that is truly performance-driven and aimed at decreasing unwanted variation in care, while being able to validate the performance so that it stands up to scrutiny.

From a leadership perspective, the unfortunate reality is that the recent focus on performance has been viewed mostly as an economic opportunity, such as the Medicare demonstration project on pay for performance.

Also, organizations are beginning to use ratings and awards as marketing tools to help move market share to them. In reality, a strong quality and financial case can be made for pursuing a performance-based culture that can be seen in the outcomes of Solucient's Top 100 Hospitals as reported on their Web site.

As a group, the top 100 were more likely to be early adopters of new technologies, had 42 to 61 percent more market share than non-winners, and very stark findings that 84,374 more Medicare patients could survive each year and an additional 53,500 patients could avoid complications if overall performance was the same as the top 100 group.

Financially, the hospitals performed remarkably better than their peers with

* A 19 percent lower expense per discharge

* Average profit margin of 7 percent compared to 2 percent

* A third of a day shorter length of stay

* 20 percent fewer staff, with 16 percent higher case mix index

* 20 percent more admissions per bed.

While from a business perspective it is appropriate to pursue improving performance, the entire profession should argue for a much higher bar to be set. Not only should performance be subject to the economic reality of the marketplace, but performance should the key driver in conferring professional authority.

If we anchor our performance as a fundamental requirement to achieve professional authority, our profession will maintain a strong position well into the future.

If we anchor our performance in economic rewards, our profession will be at risk with every economic challenge we face. In essence, our professionalism will be traded like a commodity among competing interests.

Where do we start?

So how do we begin to get our hands around performance? Creating a performance-based culture in health care seems like an insurmountable task. As leaders we are challenged daily as we work to improve performance in our own small piece of this massive system, yet, it is a challenge we must accept.

The Institute of Medicine (IOM) report actually gives us an extremely valuable blueprint on repositioning our profession for the 21st century. It truly gets to the heart of a complete redesign of our professional culture. Table 1 shows an outline of where we are and where we need to go:

The key rule in the IOM report that is vital to changing culture and embracing performance as a driver of professional authority is transparency. We need to become transparent in order to build trust and validate performance. The alternative is that the consumer will force transparency on us in order to satisfy their desire to use performance information to assist in making the choice of their health care provider.

If we accept that performance will be the window to our authority, then it makes sense to set up performance objectives that move toward this new culture. It is not a foreign concept; we do it every day as leaders and managers as we try to move the areas we influence to a new place.

We set an expectation, we assign objective measures to it, we evaluate how we are performing related to that expectation and we hold ourselves and others accountable. Our problem here is that we have to do this as a profession well beyond our areas of personal influence.

In its simplest form we need to start with policy and end with accountability, but in reality this will be a very difficult task. Even if we agree on policies that set our performance expectations, achieving accountability with our current infrastructure will be a very difficult prospect. To achieve accountability, we need to be able to measure that expected performance, which requires standardized data that are reliable.

Our lack of standardization of information is the Achilles heel in this endeavor; we must begin to fix this problem if we truly want to move our culture. What is even more disturbing is the non-standardized information we produce every day is being used by others to measure our performance as if it were standardized. This produces misleading and potentially dangerous results.

Overcoming our overall deficiency in information technology is a major issue for us as an industry. We are undercapitalized in information technology and our innovation and adoption has been slow. I would argue that improving our level of information technology across our industry will begin to drive more consistent performance. What do I mean?

Let's say five hospitals are using the same computerized physician order entry (CPOE) system that all include the same real-time decision support information, while five other hospitals have physicians still writing orders on paper.

Patients with congestive heart failure (CHF) entering the first five hospitals will have their physicians pulling up the CHF order entry template and entering the orders with the assistance of the template. If they do not put the patient on an angiotensin converting enzyme (ACE) inhibitor, a box pops up to ask the physician, "Do you want the patient on an ACE inhibitor? If not, please give a reason."

Physicians must enter something in the box before they move on. Of course, all the orders will not be the same. Appropriate variation will be present that is driven by the patients' disease process, but we know that at least the evidence-based information is addressed.

Unfortunately at the second five hospitals, we have no reassurance at all. Not only will CPOE help achieve a level of consistent performance that is based on evidence, the initial five hospitals will have similar data that are standardized to the application that is extractable and can be used to compare their performance with better reliance.

More importantly, imagine if every information system had to meet specific standards and definitions, no matter the vendor. That would give us infinite volumes of data we could access in order to drive our performance standards.

Standards needed now

Our opportunity lies not in just following what clinical standards the information technology (IT) vendors give us with the CPOE software we purchase from them, but in being involved in the development of those standards.

Not that we want everyone to be robots and practice the same way, but because we know that many times there is a best practice that should be a part of the care we deliver. We should at least have some level of expectation on how care is delivered. Not that all care needs to be the same, but where we know it makes a difference we should expect that level of care to be delivered.

An example may be seen in acute myocardial infarction (AMI); very few physicians who take care of patients with an AMI today would argue against the evidence that giving a patient an aspirin, starting a beta blocker, and using an ACE inhibitor in the face of left ventricular dysfunction will improve morbidity and mortality.

In fact, the evidence may be so strong that it may border on unethical to not offer your patient those interventions. The question we should ask is; should providers who do not offer patients an agreed upon minimal level of care be afforded the same authority in the profession as those that do? More importantly, if we do afford them the same authority, then aren't we actually saying that our professional autonomy trumps quality patient care? And isn't that what the consumer is actually afraid of as they gain more knowledge?

Why can't we get this done? First, we have not set or outlined many standards as a profession. Unfortunately, CMS has done it for us around their quality indicators. We cannot, as a profession, continue to wait for others to set our standards for us.

Secondly, we lack the information technology infrastructure across the health care system to reliably extract and evaluate performance.

Thirdly, even if we set the performance standards, we do not have the systems in place to hold ourselves accountable as a profession to perform at this minimal level.

And lastly, we have not even begun to allow the level of transparency that will be necessary to create such a true cultural shift.

Yes, the tide is beginning to turn, unfortunately it is being turned for us. Remember, in a couple of years. CMS will have access to every medication your Medicare patient is taking and they will also have access to the patient's diagnosis.

Why should they support providers who have patients with AMI's who are not on aspirin, beta blockers and ace inhibitors? And, should the taxpayer and patients themselves not be informed of this as well? Sure there are good reasons why we may not use certain treatments with certain patients, and that is appropriate. But, I believe that we can also develop a system that allows for appropriate variation and clinical judgment while we hold ourselves accountable to some agreed upon clinical standards as a profession.

I agree it is a significant challenge but it is preferable to allowing Medicare, the insurance companies, or an Internet company, do it for us.

The choice we have as leaders of the profession seems straight forward. Are we going to let the free market determine the standards of our profession, or are we going to hear the wake-up call and secure the privileged status of our profession for the next generation of health care professionals?

If we do not lead on this, then the market will, and I can see no worse outcome for our profession than to hand over the basis of our professional authority to the marketplace.

TABLE 1. Simple Rules for the 21st-Century Health Care System

Current Approach              New Rule

Care is based primarily on    Care is based on continuous healing
  visits.                       relationships.
Professionals control care.   The patient is the source of control.
Information is a record.      Knowledge is shared and information flows
                                freely.
Decision making is based on   Decision making is evidence-based.
  training and experience.
Do no harm is an individual   Safety is a system property.
  responsibility.
Secrecy is necessary.         Transparency is necessary.
The system reacts to needs.   Needs are anticipated.
Cost reduction is sought.     Waste is continuously decreased.

By Anthony Oliva, DO, CPE

Anthony Oliva, DO, CPE, is vice president of medical affairs for Bayhealth Medical Center in Dover, Del. He can be reached at 302-744-7414 or [e-mail]

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