A Culture of Character – Permanente Physicians and Associate Practitioners

quietIn her marvelous 2012 book Quiet, Susan Cain builds upon the work of cultural historian Warren Susman in describing America’s shift from a Culture of Character prior to the 20th century, to a Culture of Personality since. In the former, the Ideal Self was more about how one behaved in private – values were discipline, honor, thoughtfulness. In the latter, the Ideal Self became more about how one behaves in public – being bold and entertaining; opinions, particularly those spoken loudly, being more compelling than knowledge or wisdom.

I continue to read loud opinions declaring what doctors will and won’t do for money, particularly from individuals who are NOT leaders of physicians. Their opinions hold that physicians will achieve higher quality scores for money (actually, designing effective, efficient and safe care-systems works better), but we won’t stay at the bedside of a patient in need (see my recent rebuttal of a particularly ill-informed editorial in the WSJ).

What if a medical group’s culture determined discretionary effort of its physicians much more than money? It does in our medical group.

According to my colleague Dr. Reginald Mason, Permanente Culture is (1) physician-led, (2) patient-centered, (3) being considerate of, and accessible to, one another, (4) respectful of duty to family, and (5) deferential to team, further manifest in our culture of communication and continuous improvement. We are accountable to one another, dependent upon one another, and insist one another deliver our best for our patients.

Each large, multispecialty medical group has its own culture. A Culture of Character – discipline, honor, thoughtfulness – has always been the Permanente Way. Not a Culture of Personality. And certainly not a Culture of Money.

Intuition v EBM: in search of our soul as scientific healers

My days as president of the Medical Association of Atlanta (MAA) are numbered. In fact, I have exactly 100 days left before I turn over the reins to Dr. Lisa Perry-Gilkes. True, I’ll be Chair of the Board for the following year, but the association’s agenda will be Dr. Perry-Gilkes’, not mine. So how shall I spend those last 100 days? I’ve chosen to facilitate a discussion among MAA membership that drives to our soul as professional, scientifically-minded healers.

The influence of Science has waxed and waned in our profession for 4,000 years. In 1600 BC, following systematic observations of cause and effect, Mesopotamian healers spread butter or honey on wounds to (correctly) prevent or treat infection (see the Library of Assurbanipal, buried 612 BC and rediscovered 1853 CE). Before dying in the eruption that destroyed Pompeii, Pliny the Elder wrote (accurately) of the medicinal benefits of the twiggy plant Ephedra – later determined to be a natural source of ephedrine, the long-acting analog of epinephrine, stopping epistaxis when applied topically and bronchospasm when taken orally. And of course it was Robert Koch in 1890 who established the microbial causes of anthrax and tuberculosis, using four postulates of medical cause and effect still used today, and not just for infectious diseases.

But in those 4,000 years, we physicians used The Scientific Method for only short periods of time, interrupted by longer periods when we did not. More often during that time, we doctors yielded to intuition or undisciplined clinical experience to guide our treatment, killing a lot of people along the way. We hastened George Washington’s death from epiglottitis by bleeding him (1799). We “knew” weeks of bed-rest after surgery or uneventful labor was good for people (1950s) … DVT / PE, anyone? We “knew” Autologous Bone Marrow Transplant (ABMT) was helpful in metastatic breast cancer (1990s), without any scientific evidence to support it (required reading for all of us: the page-turner of how that happened by Welch and Mogelnicki, BMJ 2002).

You see, the inherited neuro-chemistry responsible for intuition and prediction is in constant conflict with the learned discipline of The Scientific Method. The former works well when surviving predators in East Africa, but fails us when striving to understand the complexities of the universe (special relativity, quantum mechanics), mathematics (imaginary numbers), chemistry (we can’t see molecules); and yes, the complexities of Medicine, too.

Evidence-Based-Medicine (EBM) is the product of applying The Scientific Method to healthcare; the term comes from a 1992 JAMA article written by Guyatt:

“Evidence-based medicine (1) de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making and (2) stresses the examination of evidence from clinical research (when available).”

So why would any members of my medical association, much less a sizable proportion, oppose making a definitive and unwavering commitment to use the discipline of EBM in those areas of their practice in which evidence or consensus for a best practice exists?

The stated reasons are all about perceived risk to self: (1) risk that insurance companies won’t pay the doctor for care deemed non-evidence-based, (2) risk a plaintiff’s attorney will gain the upper hand in allegations of medical malpractice, or (3) risk a hospital or medical staff will hold the doctor accountable for using clinical guidelines. But what of risk to our patients when we use outdated therapies, or poorly tested diagnostics or treatments, or place our interests before their’s?

EBM is not a panacea. Absolutely there are many times when (1) evidence doesn’t exist to establish a best practice, or (2) a best practice is later determined to be wrong. But it’s the EBM PROCESS that’s key … using available information to first craft, then continuously refine, a limited number of optimal ways for all doctors within a discipline to use when treating discrete clinical conditions, each thought to be clinically equivalent (otherwise why bother).

When clinical research is lacking or inconclusive, the Hippocratic principle of “do no harm” dominates.

We must abandon the age of blood-letting once and for all – for our patients and their families.



The TRUE Definition of Physician-Productivity Might Surprise You

In his OP-Ed in today’s WSJ, Dr. Scott Gottlieb makes several mistakes.  I have time to address only three.

“ObamaCare is gradually making the local doctor-owned medical practice a relic.”

First of all, let’s stop calling it ObamaCare.  That term is intended to be derogatory, largely borne of fear, mainly from the current Administration’s political opponents (such as Dr. Gottlieb’s employer, the American Enterprise Institute).  Noble doctors realize healthcare reform should NOT be about politics, rather improving the access and quality of care for all Americans.  PPACA isn’t making small fee-for-service (FFS) practices a relic, the industry’s and country’s macroeconomics are (see 18% GDP, see Steven Brill’s Time article, see Sequestration).  Small, single-specialty practices don’t have the expertise, physician-leadership, or measurement / improvement infrastructure to eliminate the 35% of waste in America’s care (see recent IOM report).  Only large, multi-specialty group-model practices can do that, like the Permanente Medical Groups.

“When doctors become salaried hospital employees, their overall productivity falls.”

Let’s provide the correct definition of ‘physician productivity’.  It’s NOT “see the most patients per hour as possible”, rather “solve the most patient-problems per hour”, or if you prefer, “prevent the most illness, cure the most illness, resolve the most patient pain”.  A given physician’s RVUs fall 25-35% following the transition from FFS to salary-based compensation PRECISELY BECAUSE 25-35% of the “care” in FFS (testing, drugs, surgery) is not medically necessary for the patients who experience it.   It’s high time our entire profession define Physician-Productivity along the dimensions of patient outcomes (fewer illnesses, less need for hospitals, more cure, fewer mistakes).  We’ve been doing it that way in the Permanente Medical Groups for 70 years.

“(Physicians paid a salary, rather than FFS will) no longer take the time to give detailed sign-offs as they pass care of patients to other doctors who cover for them on nights, weekends and days off.”

Money is a bad way to ensure doctors give their all for each patient.  Measurement and Culture are the ways.  When doctors are beholden to one another for quality, service, diagnostic and therapeutic excellence, their patients (and colleagues!) benefit.  The purpose of paying physicians high salaries is to compensate us for working 70 hours a week, sleeping less than 4 hours many nights, and acknowledging our high-pressure, zero-margin-for-mistakes worklife, rather than to make money for the hospital (see my recent post entitled, “The Very Rational, albeit Regrettable, Link Between Profit and Salary in Healthcare”).  Here’s the real reason practice acquisition failed in the 1990’s – once physicians no longer were self-rewarded to rack up excessive bills on their patients, they stopped.  The acquisition companies were in it for the money in the 1990s (i.e., to receive the profits of overtreatment instead of the doctors).  Had they been in the practice-acquisition game for the right reasons (to raise the quality and reduce the waste in care), we might not have needed PPACA 20 years later.

In fairness, Dr. Gottlieb gets two things right. 

“When integrated delivery networks succeed, they are rarely led by a hospital.”  True.  They are led by humble physicians, grounded in the principles of evidence-based-medicine and continuous improvement, and experienced in effective leadership.

“(Most) hospitals aren’t buying doctors’ practices because they want to reform the delivery of medical care. They are making these purchases to gain local market share and develop monopolies.”  True.  I’m not defending the purchase of physician practices by hospital monopoles or oligopolies.  And anyway, from what I hear, the FTC is gearing up to (finally) enforce our county’s Anti-Trust Statutes in this regard (let’s hope the FTC follows through on their duty).

So I guess this is my summary:  Dr. Gottlieb’s editorial is more about earning his salary from his side of the political spectrum, rather than trying to inform the discussion of healthcare delivery reform.

Symbols Can Change the World

pinkribbon1973. My high-school friend arrives home from school to an empty house. Since being told 2-weeks earlier she had breast cancer, his Mom had been silently making arrangements for surgery in another town. Neither disclosure nor discussion with family and friends, just shame and fear. Scroll forward 40 years – we’ve got races for the cure, pink shoes on NFL players, survivorship celebrations, a whole month of awareness during which time you better show up at work with a pink garment at least twice a week, or you don’t fit in. What helped the world change?


redribbon1983. I’m holding the hand of a terrified 24 year-old man dying of progressive respiratory failure, brought about by an immune deficiency syndrome we poorly understood. Other than me and the nurse, he’s dying alone. Neither disclosure nor discussion with family and friends, just shame and fear. Scroll forward 30 years – we’ve got celebrations, empathy, acceptance. Heck, we got Bono. What helped the world change?


couric2003. I’m writing a letter of condolence to the widow of my medical school friend, recently passed away from colorectal carcinoma, leaving behind a now single mom and young children. But I’ll get my screening colonoscopy next year, once I lose some weight (perhaps I’m embarrassed to be seen with only a hospital gown). Neither disclosure nor discussion with family and friends, just shame and fear. Scroll forward 10 years – we’ve got colon-prep-parties, a month to call our own, rising screening rates. What helped the world change?


nomore2013. Women are stalked, spouses battered and imprisoned, children scarred. Inadequate disclosure, inadequate discussion, just shame and fear. What can help change the world?

Throughout human history, we’ve used symbols to recognize, remember, and reform our world. Symbols can be particularly useful when addressing public health scourges. Linking the thousands of people, working in hundreds of non-profit organizations, who use many great programs to prevent and intervene in domestic violence and sexual assault, we now have this singular symbol. Wear it with pride. You might just change the world, one silently suffering person at a time.

NO MORE … it’s time men lead


I had the privilege this morning to be part of the national launch on Capital Hill of the NO MORE Campaign, seeking greater awareness, earlier intervention, and more effective prevention of domestic violence and sexual assault.

I made comments about my 28 years as a physician, during which time I helped restore the peace of mind and sense of dignity to victims of domestic violence and sexual assault. I treated physical conditions that had their genesis in the psychological trauma and PTSD of violence against women and children. But that’s not why I’m writing today.

I made comments about my 12 years as a leader of healthcare in Georgia, during which time I witnessed how focusing the public’s attention upon a public health scourge can activate Americans, leading to the prevention of illness (vaccinations) or more cancer cures (mammograms, colonoscopy, PAPs). But that’s not why I’m writing today.

8555138648_1c401ef4df_nI made comments as Kaiser Permanente’s representative for today’s launch of NO MORE, highlighting our very own Dr. Brigid McCaw’s years of clinical work in the field, which has led to substantial increases in prevention and effective treatment of our members at risk for, or affected by, domestic violence and sexual assault. But that, too, is not why I’m writing today.

As a husband, an uncle, a brother and a dad, I know that we men have the primary responsibility for making the NO MORE Campaign wildly successful. We must own at least an equal share of leading the NO MORE Campaign.

What should that male leadership look like? We men must have the “NO MEANS NO” conversation repeatedly and effectively with our sons and nephews, beginning in adolescence. We must show as much affection and admiration for our son’s respectful and honoring behavior toward women, as we do for their scholastic and athletic achievements. We must be deliberate in counteracting the misogynistic lyrics and dialogue in much of today’s music and cinema, respectively, marketed to adolescents.

Yet we men accounted for only 10% of the audience and participants at today’s launch of NO MORE. That’s got to change. That’s why I’m writing today.

The Trouble with Consumerism

Economists speak of two essential premises for a “free market” to exist for a good or service. Among the purchasing options, (1) sellers must provide true choice (e.g., no supplier monopoly) and (2) buyers must possess information (with which to compare the attributes, performance, total cost, and reliability of each choice).


Seldom do those two conditions exist for an individual consumer of healthcare. Her employer has chosen the health plan. His hospital holds a geographic monopoly. Her doctor provides false choices (“We can do [my procedure] or you can continue to suffer.”). A surgeon’s post-operative infection rate or a consultant’s diagnostic accuracy rate is not available. 

Moreover, the majority of the healthcare dollars consumed in the US each year are the result of “acute” (sudden, urgent or emergent) illness or injury.  Can you imagine going through the steps to choose your hospital destination, as you are loaded into the ambulance following a pile-up on the interstate? 

patient preparing to be transfered after MVA

To their credit, American consumers increasingly seek comparative information, particularly on the Internet, but not all Internet content is accurate or applies to the circumstances at hand.  So by and large, individual consumers use lay (rather than medical) advice from friends or family, or “gut feel” to accept or decline a physician’s proposed course of action.

Real choice is coming in the form of Health Insurance Exchanges (HIX), provided for in the 2010 Accountable Care Act (“ObamaCare”). In such a virtual marketplace, individual Georgians will be able to choose Kaiser Permanente when previously that choice was withheld by their employer.

Under such circumstances, it’s best to have a doctor (1) paid to prevent and cure illness, rather than enriched by the magnitude of the patient’s misfortune, (2) judged and challendged by colleagues on the basis of measured quality outcomes, and (3) practicing in a fellowship of altruistically-minded colleagues. Welcome to Permanente medicine and surgery!

tspmg logo, with website Sept 2012

The Morality of Resource Stewardship in Healthcare

Many of us rightly feel pride in being good stewards of life’s resources. We feel a moral responsibility to reduce, reuse, recycle – to get by with only what we need. Do we feel that same pride of stewardship when seeking healthcare for ourselves – expecting to receive only the healthcare resources needed to achieve an excellent result, no more no less?  Asked another way, do you believe we citizens have an ethical responsibility to reduce waste in our own health care?

The Morality of Environmental Stewardship

It’s Wednesday morning in my cul-de-sac. My overflowing blue bin and blue bag are clear evidence of my commitment to being a good steward of Earth’s resources. It also feeds my competitive spirit – I’m recycling more this week than my neighbor Andy (HA!), but not as much as my friend Bryan (Damn!).  Since my county began its curbside recycling program, my weekly “contributions” to the landfill have fallen by at least 50%, probably 65%.  I take great pride in that. You may be doing even more – driving a hybrid, exclusively using CFL bulbs, setting your thermostat to 67 during this winter.  Whatever steps you and I are taking, we agree it’s ethically sound, maybe even morally superior, to conserve environmental resources.

The Morality of Household Stewardship

You shopped until you dropped, comparing prices across countless physical and digital stores.  You clipped coupons or drove an extra 20 miles to save $5 (don’t do the math, it will discourage you). You make the most of your leftovers (even though most of us throw away food that 4 billion hungry people would have considered more than edible – a “sin” when I was growing up).  Again, we can agree that we feel proud when we conserve household resources.

The Morality of Healthcare Stewardship

We go to our doctor with a common complaint – one that her years of training and experience tells her can be diagnosed simply and treated reliably – yet we ask for the same battery of tests that our neighbor received from his physician.   We intuitively, and erroneously, believe that “more” healthcare is necessarily better (see my post entitled, “What will it take to Convince America that MORE (healthcare) is often WORSE”).

Most clinicians I speak to in Georgia, particularly outside of our medical group, don’t feel it’s their responsibility to manage quantity or cost of healthcare resources consumed in the course of caring for a single patient.  Or we find our patients don’t like it when we consider cost during shared-decision-making discussions (see my next post).  We justify our spending behavior in a myriad of ways … (1) the ambiguity of clinical circumstances, (2) having insufficient time to think (the waiting room is full, after all), (3) the patient insisted upon the additional testing, (4) we (falsely) believe more testing will protect us from allegations of medical malpractice, (5) the cost of healthcare is someone else’s problem (hospitals, pharmaceutical companies, health plans, etc) or (6) we want to be seen by the family as “doing everything medically possible” to achieve an improbable outcome.  Most physicians, and nearly all patients, don’t feel the same ethical twinge we get when we toss an aluminum can in the garbage instead of the recycling bin.

It wasn’t always that way.  During Morning Report at Vanderbilt in the mid-1980s, I recall having to justify every test ordered for every patient admitted. The ethic was something like this … only the best and brightest docs figure out the diagnosis fastest, implement treatment quickest, and ensure that treatment is effective for that individual patient. The process was powered by incisive clinical acumen and an intense reverence for medical reasoning.  Clearly, those docs who made the correct diagnosis most rapidly, who subjected their patients to (only) the confirmatory test(s), were superior.  It was our duty to practice efficient medicine.

Well, that ethic is making a comeback.  A coalition calling itself Choosing Wisely recently released a list of 45 tests and treatments that physicians should no longer automatically order. Dr. Christine Cassel, president of the American Board of Internal Medicine (ABIM), says the goal is to reduce wasteful spending.

“We all know there is overuse and waste in the system, so let’s have the doctors take responsibility for that and look at the things that are overused. We’re doing this because we think we don’t need to ration health care if we get rid of waste.”

Consider this sentence from a recent JAMA editorial … “Because responsible management of medical resources benefits patients individually and collectively, it should now be considered a central professional responsibility (Brett AS, McCullough LB, JAMA 2012[307]:149-150).”

It’s not easy to address requests by patients for non-beneficial interventions, but by hearing a patient’s root-cause concerns, using excellent communication skills, and engaging in shared decision making, we doctors can create excellent quality, low-waste health care that is deeply satisfying to both patient and clinician.

“How Do You Get Doctors to …?”

Much has been written lately about the rapid evolution of health care in Atlanta, which includes:

  1. Acquisitions, such as Emory acquiring St. Joseph’s or hospitals acquiring physician practices
  2. New infrastructure, including the use of electronic medical records and construction of specialty treatment centers
  3. Collaborative ventures, including the Georgia Health Collaborative and the management agreement between Emory and Southern Regional

In media coverage of these announcements, academics and consultants are often asked “How will these investments create value for Atlantans and the companies who employ them?”  It’s the right question, but by posing it to someone without clinical experience, the answer — some version of “it will enable the new entity to get doctors to …” — often ignores the needs of patients who will be impacted by these changes.

Before we get to the right answer to the journalist’s question, let’s remind ourselves of the root causes of our increasingly unaffordable, lower quality, less reliable, and less satisfying health care system in the U.S.

  1. We pay our doctors and hospitals only when they perform tests and procedures – the “fee-for-service” model. The result is substantial, costly, and, in some cases, risky overtreatment (for more information, see Dr. Atul Gawande’s article in The New Yorker, June 2009)
  2. We don’t routinely coordinate care between different clinical specialties or properly emphasize patient safety. This leads to waste and clinical misadventures (for more information, see: Institute of Medicine (IOM) Report: Best Care at Lower Cost, September 2012).
  3. We don’t focus enough on social and demographic determinants of health. Ignoring these needs means we are treating the symptoms, not the cause, of many chronic illnesses (for more information, see the 2012 HBO series, Weight of the Nation, or www.healthypeople.gov/2020).

So, the right answer to the journalist’s excellent question should be “The (investment/merger/partnership) will enable (the new/larger organization) to (1) change the mechanism of payment to doctors and hospitals to promote care quality and patient outcomes, (2) systematically hard-wire coordination of care across the organization, and (3) help individuals improve their exercise, diet, state-of-mind and environment.”

The wrong answer is “…to get physicians to do what an outside organization – a health plan, a hospital – wants them to do.”  Why? Physicians are sworn to putting the needs of their patient first. As “knowledge workers”, we must (1) gather and organize large amounts of information, some of which may conflict, (2) accurately predict the outcome of different diagnostic and treatment options, and then (3) conduct an effective shared decision-making exercise with patient and family – all before treatment begins. Organizations seeking to use their larger market or financial presence to insert themselves between the physician and patient add little value and may ultimately reduce quality of care.

As such, physicians must lead the design and implementation of health care investments that address appropriate payment mechanisms, coordination of care, patient safety, and social determinants of health. It’s a proven model – institutions such as The Centers for Diseases Control and Prevention (CDC), the National Institute of Health (NIH), Kaiser Permanente (KP), and The Mayo Clinic have long used systems of effective physician leadership to maximize the benefit to patients and the organization. It’s important we do so here in Atlanta.