Editor's Note
New and Improved?
I’m amazed that my cholesterol has gotten that much better,” exclaimed Jack as he buttoned his shirt after I examined him and reviewed his labs. I offered my usual explanations—weight down a bit, perhaps fewer French fries? But when he continued to enthuse, I gave him one of my favorite lines: “You’re not getting older, you’re getting better.” Like most quips, it has a kernel of truth with a dash of the ridiculous, and rarely does it miss eliciting at least a smile. Yet on my introspective days, I frequently walk out of the exam room after delivering this line and ask myself, “Older for sure, but are you getting better at this job?”
For most of my training, getting better at the practice of medicine meant soaking up book knowledge, gleaning clinical pointers from mentors and teachers, and acquiring new skills at the bedside or in the operating room. Improvement was expected and was constantly measured by grades and evaluations as we scaled the medical education ladder. Education didn’t stop with the completion of medical training; but once in practice, improvement required more than learning about a new antibiotic or how to do an additional procedure. We had to learn to deal with health care systems.
Starting medical practice in 1977, I saw a maelstrom of colliding systems that needed to function correctly for me to take care of patients and that could cause me to fail if they failed. If I couldn’t find the patient’s potassium result, it didn’t matter how much I knew about renal hypertension. If patients couldn’t get through my phone system, I could be Sir William Osler himself and still not be able to help them. Improving the practice of medicine means more than just improving doctors.
Improvement has become more important as everybody wants to measure doctors’ and health care delivery systems’ ability to contend with patients’ health problems. For years we’ve had the Medicas and the Blue Crosses of the world dabbling in clinical guidelines and performance goals. Pay for performance is a buzzword that pops up in most health care reform proposals. Now, encouraging and rewarding improvement in medical care delivery seems to have reached prime time. Medica is sponsoring process improvement at Fairview’s Eagan clinic and others (p. 15). The state of Minnesota has endorsed the basket-of-care model as a way of reimbursing for quality (p. 47). And physicians in Minnesota and nationwide are fashioning their clinics into medical homes in which a doctor heads up a “family” that orchestrates and directs a patient’s medical care efficiently and economically (p. 32). Improving is no longer a choice for physicians. And in the future, it will determine our paychecks.
A crucial cog in these new, improved medical systems is the computer. The medical community is still decades behind other industries in its use of computer technology in day-to-day operations. A number of physicians still don’t use electronic medical records in their clinics, and those who do frequently find their system can’t “talk” to others’ systems. Efforts are underway to change this Tower of Babel and allow medical information to flow seamlessly between all points of care (p. 26).
I haven’t given up my books and journals, and my practice functions much more smoothly than it did in 1977. I believe that I and my ability to practice medicine are still improving. Better than last year? I think so. Older? For sure.
For further insight into improving systems, health care reform, and costs, see Atul Gawande’s article in the December 14, 2009, New Yorker.
Charles R. Meyer, M.D., editor in chief Dr. Meyer can be reached at cmeyer1@fairview.org