Presidential Address from Dr Jeff Brown to the ASMS Annual Conference

Best

The best health care system in the world.

The best health professionals in the world.

The best doctors in the world.

Ideals plucked from sleep-deprivation fantasies?  Unrealistic and unaffordable ravings?  Emetic eternal optimism?

But what do our patients expect when their lives and ours intersect?  Do they expect mediocre care?  Do they expect us to achieve wide variances in diagnostic accuracy?  Do they expect us to have 275,000 adverse drug events per year in New Zealand?  Do they expect patient identification errors 900 times each year, harming 320 patients?  Do they expect potentially preventable events to be costing our health system $590 million per year?

My experience, and yours, and that of the Health and Disability Commissioner, is surely that patients expect the best care.  That they will see the best doctor to help them with their undifferentiated problem or problems.  That they will see the best doctor to help them with diagnostically or technologically challenging conditions.  That they will navigate a joined up system of best care that eases their journey rather than raising barriers or laying heffalump traps at every turn.

They expect our best efforts, singly, and together.  To put their best interests at the centre of our attention.

They expect best care, not second best.  Not third best.  Not barely good enough.

Tomorrow we will hear about the newly formed Quality and Safety Commission.  About what projects we can expect to participate in, what shared learning we can quickly disseminate.

We will be challenged to think outside our silos.  To look beyond variation.  To consider the notion that the most dramatic advances in healthcare are not in extremely high cost pharmaceuticals or whiz bang technology, but in applying what we now know more equitably.

As Richard Bohmer elegantly outlines, modern health care organisations must be capable of simultaneously optimising the execution of standardised processes for addressing the known, and learning how to address the unknown.  Health care providers need to excel at performing three discrete tasks simultaneously: (i) vigorously applying scientifically established best practices for diagnosing and treating diseases that are well understood, (ii) using a trial-and-error process to deal with conditions that are complicated or poorly understood, and (iii) capturing and applying the knowledge generated by day-to-day care.

We cannot excel at this as lone heroes, as individual autonomous doctors, as competing craft groups, or as adversarial organisations.  Our collective intelligence has more chance when we take a stance for national services, for national clinical networks, for regional solutions.  Provided we are always vigilantes for the complexity of patient care in which predictability and ambiguity exist side by side.

We will contemplate integration of primary and secondary care models tomorrow, of joining up partitions of care.  Of joining up the leadership of organisations advocating for their portion of the pie.  There is evidence out there, in New Zealand, that we can do so much better, while celebrating that we currently have one of the cheapest, most efficient, best outcome health systems in the world.

Yet even in New Zealand, if all hospitals were to meet the current average length of stay, we could save 382 beds, effectively the costs of building and running an entire new hospital.  And the ongoing capital charges and depreciation.

Just by doing what others are doing best.

But many claim that doctors are not natural team players, that stories of heroism reinforce autonomy at the expense of patient outcomes.  Mounting evidence suggests that individual clinicians, and even hospitals, have only limited control over the fate of their patients.  It all depends on complex adaptive chaotic systems, on small interventions with butterfly wing effects.  And is totally dependent on a profession that attracts idealistic people who want to do good, and selects out the smartest, hardest-working and most competitive people in society.  Is it any surprise that it is hobbled by their fierce autonomy? That medicine's altruistic core values actually reinforce practitioners' resistance to change?  That doctors see themselves as their patient's sole advocates, with the rest of the world divided into those who are helping and those who are in the way?

Medicine used to be a cottage industry of autonomous artisans.  That is how our beliefs and morals were forged.  That is what formed the framework for those who trained us.  And when we are challenged to change we argue from what we know.  And we all know best.

On the few occasions we do not confidently know, we ask for or acquiesce to a second opinion.  Yet, says Atul Gawande, the second opinion is a tremendously flawed institution.  You do not get to pick the best outcome, just to pick from two different options.  What you really want is for those two doctors to talk to each other.

When they talk to each other the patient really wants the best from both.  That doctors respect each other's expertise, whether in the minutiae or in the global aspects of the individual, their family, and their community.  That they are not tired, not grumpy, not juggling duties and dropping balls, especially if those balls are theirs.  That they know what other doctors have asked, have considered, have eliminated, and have treated.  That one part of the individual's journey is joined up to the next step they take, supported by our care.

Integrating primary and secondary care, and leadership of that care, is an increasingly important and challenging theme for hospital based specialists.  Our DHB boundary riding, or primary vs secondary vs tertiary territorialism, has made innovation as vulnerable as island species, suspended in webs of significance we ourselves have spun.   We continue to reinvent the wheel, instead of accepting the fundamental design as pretty good, and investing our energies into retreading the tyres for local roads.

Our performance variation should prompt us to work more as teams.  To change from the fables of heroism of infallible lone healers to tales of great organisations and brilliant teamwork that make for great care.  While we are the determinants of the most expensive spending in all health, we are also the levers for the greatest changes in the way we spend each health dollar.  

What determines the inventiveness and rate of cultural change of any group is the amount of interaction between individuals.  Some claim natural selection applies to shared ideas and discoveries.  And we know we are sharing and telling our stories in the modern medical age at an unprecedented rate.  We hold out hope that we will prosper mightily in the years ahead because our ideas are having sex with each other as never before.

But a caution as we rush headlong into innovation.  Social psychologist Jonathan Haidt says, although we like to think of ourselves as judges, reasoning through cases according to deeply held principles, in reality we are more like lawyers, making arguments for positions that have already been established.

We all know that our provincial and rural hospitals are under threat.  That we are reliant on locums and imported expertise to keep our communities afloat.  That we are asking a diminishing pool of fulltime hospital specialists to lead us through the exigencies of modern clinical life.  With little or no formal training in leadership.  Today we will hear the results of our survey into clinical leadership.  Into how SMOs perceive the implementation of "In Good Hands".  

We will give you the opportunity in workshops to discuss how clinical leadership is working in your world.  To identify the barriers, and how you have overcome them.  To share how you deal with colleagues who illustrate the traits of high certainty and low agreement.  And to explore how we can strengthen branch activities to best promote distributed leadership throughout our workplaces.  To work out how we can tell the best stories of new heroes who use checklists, who tell stories of great organisations and brilliant teamwork that make for best care, who drive national and regional solutions.  Vigilantes who enable ideas to be a whole lot more promiscuous.

Beyond the rhetoric, where does the rubber, even of retreaded tyres, hit the road?  Where does the best solution for our troubles lie?  In our workforce.  Without one we cannot exist, beyond the dodgy and deranged who linger with nowhere to go.  Our patients expect their doctors to be the best, not second best, or worse.  

Your Executive and negotiating team have explored innovation and collaboration with DHBs to develop both a holding pattern improvement in conditions, in line with other health workers, alongside a business case for significant investment in the senior medical workforce to retain our best minds and minders, and recruit the best intended imports.  Anticipated result - the best medical workforce for New Zealand.  We have tried our very best, and are confident that whatever the outcome of political deliberation, our shared vision with DHBs is unarguably the best view of the future for our country's health system.

In these negotiations we have adopted the forensic pathologist approach to adversarial systems.  They describe a "hot tub" process whereby proponents of arguments meet together, and over a meal, or more, develop a shared understanding, shared way through or over barriers, and shared vision of the future.  I am reminded of the frog experiment where gradually raising the temperature of the hot water evoked no response from the frogs, other than acceptance of cooking to death.  I hope that our organisation of mature health professionals, led by passionate exponents of a world class health system, are the best thermostats of our hot tubs.  And that you as delegates to this Conference will support them as they explore beyond backyard pools, into communities of care, into regions of shared services, and into national networks and nationally funded services.

And support a case for investment in the best SMO workforce possible.  To provide the best care for our population, the best care for our groups of patients, the best care for the individuals we share critical moments with.

To make them better we must be our best.

Kia kaha.