Professionalism in medicine: the new authority

For Mrs. Jones, this Monday morning is very different than any in the past.

She usually gets up around 7 a.m., but today she is up at 5:30 a.m. She is about to leave for the hospital to have breast surgery because she recently received the terrible news that she has cancer.

She arrived at this point in her life after her family doctor, whom she has known for many years and trusts completely, ordered a mammogram three weeks ago. The mammogram was read by a radiologist she never met, yet she doesn't challenge the diagnosis because she trusts the judgment of her family doctor.

She was referred to a surgeon she never heard of to have a steriotactic needle biopsy. A pathologist she doesn't know read the biopsy--she's not even sure what a pathologist does--yet the pathologist's diagnosis of cancer changed her life.

She comes to our hospital today trusting that the surgeon, the hospital and its staff are competent. She allows herself to be put to sleep by an anesthesiologist she met only this morning, and places her life in the hands of people she has only known for a little over an hour.

This scenario is played out every day in the modern health care system; it is a system built on layers of trust that seem to transcend human nature. How is it that we have developed this trust and on what authority are we relying on that provide our patients this level of trust? In other words, what is the professional authority that affords us the status we have attained in the health care system of today?

Our current reality

In the past, the professional authority of medicine was based on acquiring skills necessary to provide health care. In his book, The Social Transformation of American Medicine, Paul Starr shows how medicine struggled to create and confer professional authority.

Starr shows how we validated our professional authority by processes such as standardization of medical education, licensure, and board certification over the last 200 years. Our authority was further based on the fact that the lay public had very limited access to information and relied on the professional for appropriate recommendations.

For years this authority gave the lay public enough assurance that their health care provider had acquired and retained the knowledge and training to advise them on the best course of action for their condition.

Despite a fairly rigid process that developed to confer this authority to our profession, we still see an unacceptable degree of outcome variation involving both physician and hospital care. This should not surprise us because a natural outcome of strong professional authority is autonomy, and autonomy creates variation--how can one be autonomous, yet be just like everyone else?

The health care system in America is the shining example of this great variation in the delivery of care. Autonomy transcends all levels of the American health care system. From the individual provider to the largest integrated system, we all believe in our autonomy over how health care is delivered.

Autonomy also explains the wide variation in the delivery of health care that we see in the U.S. Examples include cardiac surgery rates or C-Section rates that seem to vary almost independently of patient demographics but actually tend to be more directly related to provider demographics across the nation.

This variation is the outcome of a system driven not by the patients but by the physicians and hospitals that deliver the care. Not only does this bring into question the overall quality of this system, but we also realize that any attempt at controlling costs and managing resources within this system is fanciful at best.

What is changing?

The old professional authority that relied on education, licensing and training is slowly and steadily giving way to a new basis of professional authority. The evolution of a new age of consumerism in the American health care system is driving a change in what defines our professional authority, and the emerging authority is slowly and surely being focused on our ability to validate our performance both individually and collectively.

The unfortunate reality for us in health care is that this is happening to us and not because of us. We find ourselves scrambling to find out where we fall in the latest Internet site that lists the "best doctors."

What is even worse is that most of these sites are making those determinations based on billing data that, even in the best of circumstances, are not always accurate and are driven by coding rules and billing procedures that are often not completely understood.

Nonetheless, it is occurring and it will only become more pervasive as the health care consumer becomes more educated, has easier access to information and begins to rely on these measures of performance to pick their health care providers.

It is incumbent on us to meet this challenge and be leaders in this process. If we do not take the opportunity to define what our new legitimate authority is, it will be defined for us.

Consumerism, performance information, marketing and a shrinking world present new and daunting challenges for health care providers. The risk of losing patients for elective procedures to other providers that may be even thousands of miles away is not futuristic; it is happening in many communities today.

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A recent example of this trend was found in the March 25th, 2004 Advisory Board Company publication "iHealthBeat" from a Wall Street Journal report that 28 large employers such as Sprint, Lowe's, and BellSouth covering more than two million employees and their dependents, is developing health care scorecards to help employees choose doctors and hospitals based on quality and cost. They will use claims data to evaluate how doctors compare to evidence-based quality standards.

As this information becomes more available, it is easy to see that our success will depend on performance and how we validate that performance. This creates a significant challenge but also provides an excellent opportunity.

The challenge is to create a culture that is truly performance-driven and aimed at decreasing unwanted variation in care, while being able to validate the performance so that it stands up to scrutiny.

From a leadership perspective, the unfortunate reality is that the recent focus on performance has been viewed mostly as an economic opportunity, such as the Medicare demonstration project on pay for performance.

Also, organizations are beginning to use ratings and awards as marketing tools to help move market share to them. In reality, a strong quality and financial case can be made for pursuing a performance-based culture that can be seen in the outcomes of Solucient's Top 100 Hospitals as reported on their Web site.

As a group, the top 100 were more likely to be early adopters of new technologies, had 42 to 61 percent more market share than non-winners, and very stark findings that 84,374 more Medicare patients could survive each year and an additional 53,500 patients could avoid complications if overall performance was the same as the top 100 group.

Financially, the hospitals performed remarkably better than their peers with

* A 19 percent lower expense per discharge

* Average profit margin of 7 percent compared to 2 percent

* A third of a day shorter length of stay

* 20 percent fewer staff, with 16 percent higher case mix index

* 20 percent more admissions per bed.

While from a business perspective it is appropriate to pursue improving performance, the entire profession should argue for a much higher bar to be set. Not only should performance be subject to the economic reality of the marketplace, but performance should the key driver in conferring professional authority.

If we anchor our performance as a fundamental requirement to achieve professional authority, our profession will maintain a strong position well into the future.

If we anchor our performance in economic rewards, our profession will be at risk with every economic challenge we face. In essence, our professionalism will be traded like a commodity among competing interests.

Where do we start?

So how do we begin to get our hands around performance? Creating a performance-based culture in health care seems like an insurmountable task. As leaders we are challenged daily as we work to improve performance in our own small piece of this massive system, yet, it is a challenge we must accept.

The Institute of Medicine (IOM) report actually gives us an extremely valuable blueprint on repositioning our profession for the 21st century. It truly gets to the heart of a complete redesign of our professional culture.