Presidential Address from Dr Jeff Brown to the ASMS Annual Conference Thursday 18 November 2010, 9:18AM
Presidential Address from Dr Jeff Brown to the ASMS Annual
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
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
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
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.