[ Music ]>>Al Mulley: Who
can fix healthcare? Some people think that
doctors can fix healthcare. Trust me, I’m a doctor;
we can’t. Some people think that their
elected representatives or other policymakers
can fix healthcare. I don’t think so —
not even presidents. If presidents can
fix healthcare, Harry Truman would have done
so just after World War II. That’s when the British, still
reeling from the psychic trauma of the near death
of their nation, with occupied territory twenty
miles away and bombs dropping on their capitol, reached out
for a sense of personal security in the form of healthcare
security, and formed the NHS
in 1948, July 5. Truman tried in this country,
but he didn’t come close. Every president since has
tried, I must say some more than others, and we’ve just
had a small victory, I think, in a battle to achieve some
personal health security. The end of that story
is yet to be written. No, I don’t think doctors or
policymakers can fix healthcare. They certainly can’t
do it working alone, and I don’t think they can
do it working together. They need you. Now, some of you may be
looking to your right, looking to your left — maybe
me, but I don’t know about him or her, and some of
you may be wondering, I’m not even sure
what the problem is; how can I fix healthcare? So who can fix healthcare? Me? Her? Him? I think you need to understand
your role in healthcare, and my guess is, you
don’t realize it. Yes, you need to understand
the problem, but you also need to understand that it’s
the decisions that you make about your health and
about your healthcare, that really drives the system. We don’t have time to get
down in the weeds here, so I’m just going to spend
a few minutes talking about the problem. We are the richest country in
the world, and we spend richly on healthcare — two point
five trillion dollars, seventeen percent of our
GDP, roughly 50 percent more than any other country. Some of you may have read
the newspaper this week, about 20 percent increases
in health insurance rates for small employers
in Massachusetts. Those of you who work
for the college know that our employee costs for healthcare are
13,000 dollars per year. Increasingly, healthcare costs
siphon money from payroll checks and from profits, putting
not only the health of people at risk when they can’t
afford it, but the health of our nation at risk. And what do we get for
this massive expenditure in healthcare? Well, if you look at the kinds
of metrics that are used by the WHO and others, we
don’t get nearly as much as we think we do. We’re so fascinated
with the high science and the high technology that we
don’t pay sufficient attention to the basics. By basics, I mean life
expectancy for men and women, infant mortality rates,
vaccination rates. For most of the past decade,
our country has ranked in the mid thirties,
despite the fact that we spend roughly 50
percent more than anyone else. Let me suggest that we don’t
have time to get in the weeds, but there are some
other important things that you don’t realize, and
let’s begin with a pop quiz. Question. Healthcare
is a good thing. True, false, or it depends? How many think true? How many think false? How many think it depends? Okay. Let me try and give you
a clue or two, for those of you who are still wondering
what the answer is. If I were able to guarantee that
you would be at the absolute top of your game tomorrow at noon,
physically, intellectually and emotionally, with or
without eight hours being poked and prodded in the
DHMC EW overnight, which would you choose? A good night’s sleep, or
being poked and prodded by strangers in the glare of EW? A second clue. What if it was my sad task
to tell you that either you or a loved one would not
be with us in thirty days? Would you prefer that with
or without three weeks of intensive care that made
the poking and prodding in the emergency room
look like child’s play? Which would you choose? The respirator, the
catheters, the infusions, or peace at the last,
at home with loved ones? Now, healthcare is not a
good thing in and of itself. It’s what economists call
an instrumental good. Healthcare is only good if it
sustains or improves health. Now, I’ve cheated a
little bit on two counts. First of all, I offered
you a guarantee. I pretended I had
a crystal ball. I don’t. No doctor does. Life is uncertain;
healthcare is uncertain. The uncertainty is
interesting in healthcare. Sometimes we’re uncertain
because nobody knows. We just haven’t done
the research. There may be a new treatment
for heart disease, for cancer, for breast cancer, but we just
haven’t done the research yet, either because we haven’t gotten
to it, it hasn’t been funded, people didn’t find
it interesting. You could call that kind of a collective professional
uncertainty. On the other hand, sometimes
the research has been done. It’s been done well. It’s just that it
hasn’t been interpreted for the patient at hand. The research was done in women. Does it apply to men? The research was
done in young adults. Does it apply to old adults? And even when the
research has been done and interpreted correctly, it
may not be there just in time to help with the
decision that doctor and patient make together. And, even when all of that
happens, life is uncertain. We can’t predict what’s going
to happen to the next patient. There, it’s all about the
risk attitudes that the doctor and the patient bring
to the decision. Sometimes we like to think
we can control the future. Sometimes we like to pretend
that we’re not making decisions in the face of uncertainty. But it’s critical that
we make the distinction between those things that we
can control and those things that we can’t, and
there’s no sector where that’s more critical
than in healthcare. I’ve cheated in a second way. I’ve talked about top of
your game, perfect health. That’s that little figure
over there on the left, on the one hand, and
death on the other. There’s a lot in
between, isn’t there? We could talk about those
dimensions of physical fitness, of intellectual capacity,
of emotional resilience — all of those things contribute
to the gradations of health between perfect health
and death. And you know what, many
people would be surprised at how much they might
disagree about how good or bad a particular
health state is. For instance, men of a certain
age; I won’t mention it, learn that their urinary
functions declines over the years. They may have to get up
once or twice a night if they drink after 6 o’clock. They may have to stop 2
or 3 times on a long trip. They may have to sit on the
aisle at an event like this. And that can usually
be fixed pretty quickly with a surgical procedure, but it almost always
produces a certain odd kind of sexual dysfunction. Some men are perfectly happy
to trade away sexual function for some improved urinary
function; others are not. They disagree. When a woman is told that
she has breast cancer, she might feel that keeping her
breast is not terribly important to her, and it would
be just awful to have breast cancer occur in
a breast that she chose to keep. Another woman might
feel just the opposite. They might disagree. It’s this uncertainty
and disagreement that makes healthcare
so complex, and I think you can begin to
see why your role in sorting out the complexity
is so important. This is after Ralph Stacey, Management Organizational
Behavior professor in Hertfordshire, England. It’s called a Stacey diagram. Basically, when uncertainty is
low about getting B if you do A, and disagreement is low
about how good or bad B is, decision-making and
execution can be simple. When uncertainty is high
and disagreement is high, decision-making and
execution can be chaotic. Most of life and certainly
most of healthcare, is in this zone of complexity. It’s the profession’s job to
reduce the uncertainty as much as possible, but remember,
there’s going to be that irreducible
uncertainty left. It’s not the profession’s job
to try and get people to agree, to try and get two men to
agree about the tradeoff between urinary function
and sexual function, two women to agree about how bad
it is to live without a breast, how bad it is to live with
the prospect of a recurrence. Now, this complexity
is very interesting, and it may remind some of you
of the phrase, “fog of war.” Fog of war is the phrased
used when people have to make decisions
in a great hurry. And those decisions are made
in the face of uncertainty and ambiguity, and often
faulty intelligence. It’s often a phrased used
when things aren’t going well. I think we’re dealing
with a fog of healthcare. What can we see in
the fog of healthcare? Well, forty years ago, Jack
Lindberg, who went from Hopkins to Burlington, discovered
something very unusual. He went there to try and
document that some people in Vermont were getting far
less care than they needed. In the process, he discovered
that variation in rates of surgery were dramatic. You could grow up in one
town and be three, four, five times more likely
to have your tonsils out by the time you
were fifteen. You could grow up
in another town and be six times more
likely to have your uterus out by the time you were
fifty-five than in another town. So geography was destiny. The medical care wasn’t
driven by the science. The care you got depended
more on where you lived and who you saw than who you
were and what you cared about. So what else can we see
in the fog of healthcare? That work extended to what’s
now the Dartmouth Atlas. Over three thousand hospital
market areas coalesced around three thousand
hospital referral regions. People who live on the West
Coast are twice as likely to have back surgery than people
who live on the East Coast. People who live in Seattle,
men who live in Seattle, are six times more likely to
have a radical prostatectomy for prostate cancer than
men who live in Connecticut, but they’re also more likely to have alternative
treatments for prostate cancer. The real variation here is how
hard you look for the cancer in one place as opposed
to another. There’s also great variation
on the little things. You know, there are
eighty million people, eighty million adults
over age twenty with hypertension in
the United States. I’m sure there are
quite a few here. And occasionally, you’ll get
your blood pressure medicine changed, and you’ll
be told to come back to monitor the effect
of that change. You could be told to come
back in two weeks, two months, two years, and no one
has done the experiment to tell us which is the best. Given that there are
eighty million people with high blood pressure,
that’s a pretty expensive bit of ignorance, isn’t it? Do you know that there are
some parts of the country where people see
eighty specialists in the last six months of life;
others where they see eighteen; where they spend sixty,
seventy days in the hospital in the last six months of life; others where they
spend twenty-seven; ten days in the intensive
care unit, others where they spend two. Again, huge financial costs
but real human costs, too. The majority of people who say
clearly that they want to die at home die in the hospital. This work has been
going on a long time, emanating from Dartmouth. It took Atui Gawande’s
article in June of 2009 to catch the President’s
attention. And what he said was, this is
a problem we’ve got to fix, and again, I’m here to tell
you that you don’t realize that you’re the only
ones who can fix it. I think that if you think
about leading us out of the fog and how you can do that, it’s
worth pausing for a minute and thinking about
leadership in the fog of war and in the fog of healthcare. It’s pretty clear, rules of command are pretty
clear in the fog of war. An officer gives an
order; the troops follow or face court martial. It’s different in
healthcare, isn’t it? You don’t face court martial if you don’t follow my
orders as your doctor. In fact, you know that it’s
my responsibility to look out for your interests and
try to elicit your concerns. What does this illness,
the potential treatments, the potential outcomes
mean to you? You are the principal;
I am the agent. The goal is to be sure that
you get the care you need and no less and the care
you want and no more. This is a very simply
rule that people who talk about complexity point to
as the way out of the fog. Simple rules, direction setting,
the care you need and no less, the care you want and no more. A second simple rule. There should be no
decisions made in the face of avoidable ignorance. Anyone want to argue with that? Every decision, every
decision, about health and healthcare should
be informed by both professional knowledge
and personal knowledge of the kind that we’ve
been talking about. And if we can do that, we’re not
just talking about your welfare and the costs of healthcare, because if we had
your knowledge, we would be doing far less
aggressive care in lots of domains that we don’t
have time to talk about. If we had your personal
knowledge factored into decisions, we would also
have your revealed preferences. Those of you who remember Adam
Smith in the Wealth of Nations, unless we know what
you care about, unless you’re informed enough
about the choices that are made to reveal your preferences, we
have no information with which to shape the healthcare system
by investing or disinvesting in different capacities
to do things. Might we have too many
intensive care units? Might we have too many
cardiac care surgery suites? So we’ve lifted the fog a
little bit; the care you need and no less, the care
you want and no more; no decision about health and
healthcare should be made in the face of avoidable
ignorance. This may all sound good,
but it’s going to be hard. It’s going to be hard. I’m not sure that you
appreciate how hard it might be. First of all, you have
to up your curiosity. I’ve been trying to do that. You also have to recognize
that you need some competence. How do I understands my
choice in the context of my values and consequences. This is hard stuff. The uncertainty applies to
all of the diagnostic tests. Those of you who learned Bayes’
theorem in finite mathematics, I learned it from Jon Kim. He recognized that
part of this fog of healthcare is
the haze of Bayes. It’s hard to keep these
conditional probabilities and other things sorted out. Computers can do it easily, and that’s where
decision support comes in. But you’re at least going to
have to recognize the importance of understanding the pitfalls
that one can fall into. But in addition, there
needs to be courage. How do I accept,
how do you accept, the personal responsibility for
decisions that influence health? You’re not going to
have to do it alone. The complexity of healthcare
requires that the best thinkers from across disciplines
come together. That’s where the
ideas for innovating and developing healthcare that
minimizes the misalignment of interests between
patients and physicians, between principals and agents,
that contributes so much to the waste in our
healthcare economy, that’s where that comes in. And we’re not just talking
about the science disciplines, medicine, public health,
the hard sciences. We’re talking about
the social sciences, and we’re also talking
about the humanities. But the best thinkers
across disciplines need to be intentionally connected to
the best doers across contexts. The very best ideas for redesigning care
will succeed wonderfully in some contexts but
fail miserably in others. Unless you have a portfolio
of contexts, you’re going to discourage some
very good ideas. And both the thinkers
and the doers need to be working very closely
with the best communicators. We’ve always had a
focus on basic science and medicine in this country. I’ve already alluded to that,
what is the pathophysiology. Clinical science,
what is the diagnosis and the appropriate
intervention. The first Center for the
Evaluative Clinical Sciences was founded here in 1989. That’s the question, does
the intervention work and is it valued? What we’re talking about is
applying the same discipline of science, but also discernment
from gathering experience from across contexts,
and recalling that, the science of healthcare
delivery. I want to close with
one quick story. Jack Wennberg was not the
first to discover the variation in tonsillectomy
rates among children. J. Alison Glover did in 1938. He called it the “Strange
Bare Facts of Incidence.” Children in different
school districts in England and Wales were ten times
more likely than others to have a tonsillectomy. Mortality rates with
tonsillectomy as opposed to medical treatment
were eight-fold higher; ten-fold greater exposure, eight-fold greater
risk of death. When he read that
paper on Wimpole Street at the Royal Society of Medicine
in 1938, the representative from the Medical
Research Council said, “This seems to be an operation
for no particular reason and no particular result.” The President of the Royal
Society of Medicine said, “Yes, and isn’t it a shame that
so many children died.” Anesthetic deaths
for an operation with no proven benefit. The same variation in
tonsillitis can be raised within countries and among
countries persists to this day. Remember the curiosity. What if a parent had
asked: how do you know that this is right for my child? What if you asked every time
you had a recommendation: how do you know that
this is right for me? If not here, now and us, where, when and who will
fix healthcare? Thank you.