As I blogged about on Friday, I was back at my alma mater, Northwestern, for a football game this weekend– well, actually, I was at Wrigley Field instead of our usual home stadium. The “confines” of “The Friendly Confines” (as Wrigley is called), led to some unusual “standardized work” for the game, which left some fans unhappy. I was lucky to be on the “good” end of the field where the teams were headed all game (see left, a rare instance where NU was about to score).
During a pre-game tailgate party, I was talking with an old friend who is now an Emergency Department physician somewhere in the U.S. (I'll protect his anonymity here). As we chatted about my work and his, he agreed that there's far too much waste that gets in the way of him doing is job properly. But he also highlighted a particular problem that is NOT being addressed under the Affordable Care Act (aka health insurance reform).
For one, he said morale is so bad among physicians that a vast majority of them don't look forward to what it will be like to practice medicine in 20 years. As I've blogged about before, slashing the price that's paid to doctors and hospitals is NOT the same as true cost reduction. Medicare and Medicaid slashing the price paid to doctors is just as dysfunctional as the old “Detroit Three” supplier bullying (which stood in stark contrast to a more collaboratives approach from Toyota and others) – good article on the contrast here. If it's a car company or a health insurer, demanding price reductions will often just lead to people finding more creative ways to get paid the same as before. You can't just “beat up on your suppliers.”
I asked about his first priority as a doctor – was it trying to do the right thing for the patient instead of thinking about cost effectiveness? He said no, that his first thought was absolutely about “defensive medicine” or thinking about all of the non-preventable things that COULD go wrong with a patient that they could potentially be blamed or sued for.
I don't at all remember my friend as being a huge cynic during college. He said medicine has done this to him, basically.
Through the defensive medicine, he said they feel forced into ordering all sorts of unnecessary diagnostic work – labs and radiology, or they'll admit patients when it's not really necessary. In the Lean world, we might call this the waste of “overprocessing” – doing work that doesn't add value to the patient.
My friend said “50% of the stuff we do to a patient harms them” as the built up radiation given by CT scans might cause cancer or unnecessary admissions create the risk of infections or medical errors that result from process problems.
He knows this isn't good, but he has to protect his career and his family. Again, he was apologizing for being cynical, but he said that the cancer that's caused by all of the CT scans (from a “frequent flyer” patient, for example) isn't likely traced back to them specifically as a doctor or as a hospital… so they take the short-term action at the possible expense of the long term.
I guess you'd have to be a real hero to risk your career and livelihood by always doing the right thing? First do no harm? As John Toussaint pointed out in his book On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry, the phrase “do no harm” doesn't really appear in the Hippocratic Oath as such.
It's no wonder that my friend says nobody is recommending that their children go into healthcare and many of his doctor buddies wish they could leave the profession.
This certainly seems to be one of the sad high-level problems in healthcare that's well out of the scope of what Lean can fix…
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