Wandering in the desert: lessons from a life in health care. (Careers: Special Report).

IN THIS ARTICLE...

A physician executive who's worked in many different areas of health care explains the nearly universal problems he's encountered with the "broken" He also suggests ways to fix it.

My career path is not a straight flat highway. It's a long and winding road.

I have supported my family as a:

* Practicing surgical and cytopathologist

* Course director for a medical school pathology curriculum

* Interim head of an academic pathology department

* University medical director of managed care

* Director of outpatient medicine

* Pathologist-in-chief for a statewide integrated delivery system 

* Executive search consultant

* President of the genomics repository of a genomic startup company 

* Chief knowledge officer for a biotechnology startup company

* Managing director for a fledgling New York City-based proteomics venture capital fund

* And presently, president and CEO of an educational and research consortium in Grand Rapids, Mich.

Interpreting the success or failure of the above career path varies depending on the evaluator.

My more traditional, academic physician colleagues shake their heads and wonder what went wrong with a once promising professional trajectory headed toward a medical school deanship. They may think: Kent Bottles cannot hold a job due to some professional and personal deficiencies.

My classmates from college who studied Eastern languages and religion with me at the University of California at Berkeley approve of the career meanderings that support their more right-brained view of the way the world works. That translates as: Kent Bottles is so talented that there are an endless variety of ways he can earn a living and make a contribution to society.

For me, it is what it is: a way for me to explore my strengths and weaknesses within the confines of requirements to contribute to the support of my daughter and son.

So what have I learned? What has more than 20 years in health care taught me?

1. Skilled and ethical physicians are practicing in a broken system that fails to provide job satisfaction for providers arid quality care for patients.

2. Health care providers are out of touch with their customers.

3. Health care organizations do not know how to hire the workers who can address these two fundamental problems.

Job satisfaction

Nobody is all that happy with the health care system: physicians, employers, patients and government experience its failings every day. The system is broken because it provides poor quality care, no matter how hard the professionals try.

It is important to recognize that the system is failing; it is just as important to recognize that individual professionals are doing the best they can, trapped in a failing system.

The rational part of my brain can no longer ignore all of the epidemiological data arriving at a firm diagnosis of serious problems in the quality of health care in the United States. The audiences I meet all over the country do not care if the correct number of hospital deaths associated with serious iatrogenic injury is 44,000 a year or 98,000 a year or 180,000 a year.

The public is starting to demand that something be done. How else are we to interpret the Institute for Healthcare Improvement's Don Berwick, MD, being listed third on Modern Healthcare's 100 most powerful list?

I have heard David Lawrence, MD, the former CEO of Kaiser and the author of From Chaos to Care describe how his mother was cared for by 10 MDs, 40 nurses, 15 physical therapists and five social workers during her four days in the hospital and three weeks in the skilled nursing facility.

I have heard Berwick describe how "it nearly drove me mad" when his wife was hospitalized at Brigham and Women's Hospital for an autoimmune disorder of the spinal cord. Sooner or later we'll all have a loved one in the hospital for a serious illness.

My father died last year in Seattle and I also had the "it nearly drove me mad" experience. The "it" is the lack of coordination and communication between skilled health care professionals who practice in a broken system.

Lawrence calls them information blocks, inadequate communication between providers and facilities and poor knowledge management. Berwick calls them system problems.

My mother, a nurse, just calls it a mess and wants to know who is accountable for the fragmented, disorganized, uncoordinated care that my father, Frank, received in the last months of his long life. And I still feel guilty because I, the only physician in my family, could not pull strings and fix all the problems.

Conscientious, bright, hard working, caring physicians are leaving clinical practice because they don't like practicing medicine in a system that is broken. And they don't think it is fair to be held accountable by the patients or the legal system for bad outcomes they cannot entirely control.

The accountable unit in health care is not a single Dr. Marcus Welby or Dr. Kildare. The accountable unit has to be that team of professionals working for different organizations who took care of Lawrence's mother, Berwick's wife, and my father.

Poor communication

Health care providers are out of touch with their customers.

If I learned anything from my sojourn in biotech, it was that making money and satisfying customers go hand in hand. When I look at health care from the perspective of a biotech executive, I see an entire industry that ignores its customers and fails to learn from others.

The evidence that health care is out of touch with customers is everywhere and easy to document. A recent Archives of Internal Medicine article found that physicians were much less likely than the public to believe that quality of care is a problem (29.1 percent vs. 67.6 percent; P<. 001) or that a national agency is needed to address the problems of medical errors (24.1 percent vs. 59.8 percent; P<. 001).

The articles reporting that more Americans visit alternative medicine healers than primary care medical doctors or that Americans spend billions of dollars out of pocket for alternative non-MD care only confirm what anyone listening carefully to the public already knows.

I detect a deep cynicism in the public about all experts, not just health care authorities. And who can really blame them? In the last few months:

* I have watched expert profilers on cable television make predictions about the Washington, D.C.- area snipers; and by my count, all of these predictions were completely wrong.

* I have listened to a National Public Radio newscast detailing nutritional research that contradicts the food pyramid that is. enshrined in medical and government flyers as the basis for a sound diet.

* Reading newspaper accounts of the performance of the American intelligence community to protect America pre- and post-September 11 does little to allay this widely held view that experts may not know so much.

It would be a mistake for health care to ignore the fact that I the Internet and its ability to provide inexpensive and readily accessible information to anyone with a computer and a modem creates a society that demands transparency. Look no further than the American Catholic Church or Enron to find institutions that are struggling with explosive situations that have been largely hidden from the public.

The Internet culture will not allow institutions like health care to hide behind a curtain claiming that health care is too complicated for the public to understand.

If Americans use the Internet to negotiate aggressively and shrewdly for each option on a new car and even know the precise cost of a side airbag, why would they expect less precise pricing information from physicians and hospitals?

If Americans use the Internet to cut out the middleman on hotel rooms and airline flights, why wouldn't they use the tactic with health care providers?

The public, government and employers will deal with the quality and patient safety issues with or without the cooperation and expertise of health care providers.

Unprepared workers

Health care organizations do not hire the workers who can address these two fundamental problems.

Working in biotech forced me to look at how to hire people. And I am still convinced that the most important task for any leader is recruiting people to help him. When dealing with new situations, new technology and uncharted waters, experience suddenly becomes a lot less relevant.

And yet in health care, we still cling to our old notions that we know how to hire the best people. I wonder about the practice of always hiring a chief operations officer to become a hospital CEO or recruiting a successful National Institutes of Health researcher to become chair of the department of internal medicine at an academic health science center that is losing money and dissatisfying its patients.

David Leach, executive director of the Accreditation Council for Graduate Medical Education shared Dee Hock's VISA hiring criteria with me that puts experience at the bottom of the following list:

* Integrity

* Motivation

* Capacity

* Understanding

* Knowledge

* Experience

I cannot help but observe that everyone in health care seems to reverse this list when hiring for important leadership positions. Anthony Bourdain makes the same point in the book Kitchen Confidential about hiring workers for his restaurant.

"Character is far more important than skills or employment history," he writes. 'Skills can be taught. Character you either have or don't have. There are two types of people in the world: those who do what they say they're going to do--and everyone else."

Many attribute Southwest Airlines' success to hiring people based on their attitude not their experience. Health care would be wise to learn these lessons from VISA, restaurants and the most successful commercial airline in America.

In order to address the problems of poor quality and customer service, we should hire health care leaders and workers who will fix the broken system, not leaders and workers with vast experience in the system that we all acknowledge is broken.

The airline and nuclear power industries improved their quality by redesigning their systems to minimize human error, not by focusing on individual culpability. Students of industrial human errors have learned about latent errors, the chain of evolution of events and the importance of communication between team members. How the lessons of other industries can help medicine is summarized in Marilyn Sue Bogner's book Human Error in Medicine.

My experiences in biotech convinced me that addressing these problems would require a revolution in the medical workforce. A systems approach can work, but it will require a different workforce than the one we currently employ.

In order to fix the system problems, we must be willing to use the advanced management tools that allow Boeing to map out the 3,000 steps to produce a 777 airplane.

The culture that allows Boeing or GE to tackle system problems is quite distinct from the medical culture. Most corporate cultures:

* Are dominated by one or two major personalities

* Are dependent on structure

* Have layered hierarchies

* Have policies and procedures that monitor behavior

* Expect teamwork

* Encourage collaboration in decision making

* Expect identification with the organization

Sociologists who study medical culture find physicians who are bright, independent, resent rules, policies, and procedures, resist being an employee, do not consider medicine a business and identify with the profession, not the local organization.

Many physicians who have come to me for help in leaving clinical medicine are no happier in corporate positions than they were in clinical ones.

Change

Physicians either have to change their orientation to a systems approach or risk becoming irrelevant to the most pressing challenge facing medicine.

Author Atal Gawande argues that system competence is more important than individual physician skill in providing the quality medical care the public will increasingly demand.

"The key difference was in communications--whether there were regular meetings and good relations among nursing, medical and surgical staffs involved in care, whether protocols were in use, and so on. Overall, the evidence is still fragmentary, but as surgery has become more complex, the central role of the performance of the system--meaning the teams, the technology, the infrastructure--has become increasingly obvious. There is reason to believe that advancement in system performance represents the next great frontier in advancing outcomes for surgical patients."

The physician leader of a fast learning team told an investigator, "The surgeon needs to be willing to allow himself to become a partner (with the rest of the team) so he can accept input."

Physicians are not used to teamwork that rewards "tacit knowledge" that "involves things like knowing how to manage yourself and others and how to navigate complicated social situations."

Physicians who thrived and were rewarded by the educational system because of individual IQ and effort find "tacit knowledge" to be a largely foreign concept.

Richard Wagner, a researcher at Florida State University, notes this tension. "What IQ doesn't pick up is effectiveness at common-sense sorts of things, especially working with people. In terms of how we evaluate schooling, everything is about working by yourself. If you work with someone else, it's called cheating. Once you get out in the real world, everything you do involves working with other people."

Workers dedicated to a systems approach must, like all biologic systems, learn by feedback and most of us need work at accepting constructive feedback. At the Grand Rapids Medical Education and Research Center for Health Professions, an ideal employee characteristic is to "provide constructive feedback, both positive and negative, to all including the CEO" and to "accept feedback, both positive and negative without being consumed by the perceived criticism."

As someone who is now responsible for the education of resident physicians, third- and fourth-year medical students, nursing students and health professions students, I recognize the enormity of the task ahead.

The challenges outlined in this article will not be met by changes around the edges; they will require honestly facing up to how messy, uncertain, and also surprising medicine turns out to be.

Let us begin.

RELATED ARTICLES: Recommended Reading

Gawande, Atul. Complications: A Surgeon's Notes on an Imperfect Science. New York, Metropolitan Books, 2002.

Gawande, Atul. "Creating the educated surgeon in the 21st Century." The American Journal of Surgery, Vol. 181, 2002, pp. 551-556.

Gladwell, Malcolm. "The Talent Myth." The New Yorker, July 22, 2002, PP. 28-33.

Lawrence, David. From Chaos to Care: The Promise of Team-based Medicine. Cambridge, Perseus, 2002.

Roman, Michael. "100 Most Powerful" Modern Healthcare. www.modernhealth care.com.

Berwick, Donald, Godfrey, A. Blanton, Roessner, Jane. Curing Health Care: New Strategies for Quality Improvement. San Francisco, Jossey-Bass, 1990.

Millenson, Michael L Demanding Medical Excellence: Doctors and Accountability in the Information Age. Chicago, The University of Chicago Press, 1997.

Kent Bottles, MD, is president and CEO of the Grand Rapids Medical Education & Research Center for Health Professions in Grand Rap ids, Mich. He can be reached by phone at [phone] or by e-mail at [e-mail].