Initial reflections.
For many years and in a wide variety of public and private forums, the alternatives and actions that must be conducted to achieve the transformation of our country’s health system have been commented on, discussed, and reached different levels of analysis, both in the public and private spheres, in favor of patients, who are the logical axis on which the health system of our country must work.
The work that I present assumes as its primary purpose reflecting on some actions that I consider necessary to be implemented, from a personal and institutional self-criticism, and as a result of the experience that I have acquired through working just over 21 years in ABC Medical Center. And it is not only due to my experience in this great Institution, but also to the opportunity I have had to get to know other private and public health centers in Mexico and the United States of America, as well as the experience acquired while exchanging points of view and learning about these centers’ problems as a result of many hours of talks and interviews with hospital directors, doctors from different specialties, nursing staff, and many other clinical health professionals with administrative/operative duties, some experts in the field, federal Health Secretaries, by participating in forums and the most relevant, personally, in my responsibility as general director of the ABC Medical Center from the end of 2007 to date. As director, I have had the opportunity and the obligation to listen to patients and their environment, about positive experiences and also, unfortunately, negative experiences. I must clarify that as a result of my position, these interviews with patients and their environment are not only limited to patients treated at ABC but are also extended to patients from other public and private hospitals in Mexico, the United States of America, some Latin American countries, and Spain to a lesser degree.
I am certain that what I present here is not new, that it has been, as I already mentioned, discussed, and analyzed hundreds of times. However, I do it from the moral authority of working for ABC Medical Center, an institution that is considered by many and in many places as an example and that could have stayed in its comfort zone of serving a high-income population. Instead, aware that our organization’s origin is based on helping the most vulnerable people regardless of their financial and social status, race, gender, or religion, because they have lost the most valuable thing that human beings have, which is health, and since ABC Medical Center is an organization with an exemplary philanthropic spirit since the beginning with the founding of the American Hospital in 1886, and thanks to the courage and moral honesty of the women and men part of our Board of Trustees, we made an act of contrition with the main purpose of changing ourselves and also, why not, of being an example for those who want to take up the challenge and move from discussion and analysis to concrete facts.
We should accept that change entails risks and that we are aware that any change of great magnitude is not easy and takes time.
We do not intend to boast of having the necessary knowledge and ability to have found the answers to all the approaches presented herein. We want to humbly recognize that we need to change and we want to do it and that change will often mean sacrificing benefits in the present for the sake of offering the possibility of a better future for others, since it is likely that most of us who are working and promoting this change today, will see, at best, just a few results. However, since we have inherited a solid and exemplary philanthropic and medical tradition, we are committed to providing the new generations of Mexicans with a committed and strengthened Medical Center, aligned with the desire of our founders: to help those who need it without any type of economic, social, race, gender, religion, or sexual orientation discrimination.
Change opportunities.
In an ideal world, changes would have to be promoted and executed in times of prosperity, when the wind blows in our favor. The problem with this is that when things are going well for us, something inside us tells us: why change? “if it ain’t broke, don’t fix it”; in management, as in much of life, when the short-term results are good, not even excellent, but simply good, human beings do not want to change. Leaving the comfort zone requires a double sacrifice since, on the one hand, you have to abandon the safety of the moment and, on the other, assume the risks and uncertainty of change.
And it is not for lack of opportunities, since there are, have been, and will continue to be. The thing is that opportunities must be sought and worked on, I mean worthwhile opportunities, those that, if taken, leave their mark, create culture, and move organizations.
Now that our country is experiencing a moment of change and that this is taking place in unfavorable situations in many aspects, it is no longer a matter of whether we want to change or not, it is a matter of recognizing that we need to do so, because those negative aspects that we knew existed and that, despite of talking about them, were somehow hidden or we hid under good results, are now much more visible, they are no longer hidden behind the good times, but are shown before us, reminding us that they have been there and that far from dimming over time, and because they were not attended to, they have become stronger and need immediate attention.
We need a new care model.
Our public and private health care model needs to be redone, not “patched up” as has been done for decades (a situation that is not exclusive to the health system, but we will not address that topic today).
There have been several occasions when we think – rather we deceive ourselves thinking – that any “fix/patch” to the model necessarily has to be shown as an improvement to it. This is due in part to the fact that we tend to oversimplify the shortcomings of the model, either due to lack of depth of analysis, lack of patience, intelligence, or practicality, since we detect an opportunity for improvement that is easy to apply and that will give us immediate benefits and we take it knowing that it will be short-term and will not improve any of the model’s problems. The short term often clouds ideas and conditions the long term.
And since many of us integrate the model, even more than some would like to accept, and since some participants have greater visibility and specific weight than others, the model is being patched and adjusted, in the best of cases, for the benefit of a few and almost always of the same people, since the economic and professional incentives have been aligned in some way, which undoing has a high cost, great effort, and significantly affects interests.
The point is that if you don’t change, even those who still benefit from the model, and please don’t think about the patients at all, they will lose their current and future benefits. Plainly said, there will be bread for today, but hunger for tomorrow.
I like to use a metaphor, proposing that the model resembles an old quilt that we have mended for many years, that it does not cover all of us and that we pull hard to get covered and by pulling it tears, and when it tears it needs to be mended once again, a new patch that only manages to maintain the existence of the old quilt, but now older and weaker, which still does not cover all of us as much as we would like, but since we have no other, it will continue to be pulled by all of us, in an endless fight because everyone continues to see for themselves. It will tear again and be patched again until one day it can no longer be fixed.
Transparency.
This is perhaps the most difficult battle to fight, not because others are easy at all, but because the lack of transparency in health care models worldwide has been and continues to be a deficiency. However, when analyzing care models from other countries, we have to recognize that, in the last 20 years, advances have been made to which we cannot even remotely compare.
In fact, the resistance to making care processes transparent is probably the greatest resistance of the members of the current care model, because this transparency includes the patients’ rights to ask all the necessary questions and to know and understand simply and clearly what is being explained by the doctor, or the administrative personnel in charge, about the type of illness, treatment options, inherent risks of performing certain treatment or of not performing it, the quality of life or expected survival, the total cost of it, and a significant number of etceteras that today are not part of the care component in the vast majority of cases.
And it is evident that we are facing a case of extreme information imbalance, which is not exclusive to medicine, but which should lead us to make an enormous effort to close the natural gap, between those who have knowledge that is not part of common knowledge and those vulnerable and in need of us.
Originally, the doctor-patient-hospital relationship is characterized by great information imbalance. It is our responsibility to establish mechanisms that provide better and more information to the patient and their environment regarding diagnosis, treatment, alternatives, cost, quality of life, etc. To the extent that the patient and their companions are better informed, they will participate more and the result will be better for everyone.
Of course, transparency, or rather the lack of it, is based on economic, professional, and personal incentives that are very difficult to overcome, align, and absorb, and all of us, because patients and their environment are both victims and villains of the problem, will have to establish clear rules and learn to live and coexist with them. It will take years because it implies a change in our culture as a whole.
Efficient financing systems.
Of course, the value chain in medicine is much more complex than doctors, hospitals, and insurers, however, it is in these three participants where the most critical process in patient care is found. With the current costs of care and without adequate coverage, it is absurd to think that the population we serve, even those belonging to the most privileged economic sector, can afford them.
To varying degrees, this is an unpleasant issue for everyone, an issue that some dominate more than others and that, if not solved from the root, the great deficiencies of the current financing systems will end up sinking the model into a great crisis, either in public or private terms, since pretending that the cost of care is mostly “out of pocket” by the families or that it be subsidized directly from public spending, is already a utopia.
In the private sphere, it is necessary to eliminate the fee for service which has been the economic mainstay of hospitals and doctors for decades, since both, having to obtain fair payment for the services they provide, they should not, in exchange for this fair payment, avoid responsibility with the expected result, understanding that medicine is not an exact science and that limits must be defined, a difficult but not impossible task.
Until another financially efficient method is known, the mutual benefit model is the only one with the obvious necessary urgent and required adjustments, in such a way that they can create the necessary economic wealth to meet the demand for health services of an increasingly older population that suffers from incurable but treatable and expensive diseases.
Although prevention is an effective tool that should be used, it is undeniable that prevention and education for a healthy life during childhood, youth, and middle age will not prevent millions of people from reaching an advanced age, contracting chronic diseases, and therefore requiring very expensive care services, medications, and clinical and surgical procedures.
Will we condemn millions of people who suffer and will suffer from incurable diseases to a miserable life even though current medical science can offer them a good quality of life, due to lack of economic resources? The obvious answer is no, however, under the current public and private financing systems, the reality will be different.
To a large extent, it is a matter of the values and culture of the members of the model.
In his talk “How Do We Heal Medicine,” Dr. Atul Gawande reflects on what medicine was like in the pre-penicillin era (Sir Alexander Fleming 1928). He mentions: “It was simple, cheap, and inefficient. Virtually a single physician could retain all knowledge; in hospitals, sick people received warmth, some food, shelter, and perhaps the careful attention of a nurse; medicine was seen as an art.”
Dr. Gawande continues: “Doctors’ culture and values, almost all men, were explained in being brave, independent, and self-sufficient. Today, there is a treatment for almost all diseases, more than 4,000 surgical procedures can be carried out with very advanced technology, and more than 6,000 medications can be prescribed.
However, the cultural values of most doctors have not changed and we need to change that culture. Instead of those mentioned above, Dr. Gawande proposes that the values should be humility, discipline, and teamwork. The cause of our problems, in many ways, is the complexity that science has given us. Making work systems work must be one of our great objectives, Gawande proposes.
For more than 100 years, the education of physicians in training has been based on the work described in “The Flexner Report”, a study for medical education in the USA and Canada, prepared by Abraham Felxner in 1910. This report’s great contribution was inspired by German tradition, in the in-depth study of biomedical sciences, and in the need to get medical students out of schools and that their training was done in hospitals so that doctors in training could practice on real patients.
The education model has consisted of promoting individualism, instilling the personality of a hero or heroine and not that of teamwork.
It is convenient to take some ideas from a Harvard Business Review article “Turning Doctors into Leaders” written by Thomas H. Lee, where the general profile that we find in the most active doctors today is better explained and what they are and have been for many years the “role model” of doctors in training.
- Mostly men who learned medicine when it was considered more of an art.
- Sacrificed and dedicated to the patient: arriving at the hospital from dawn, being close to the patient until they get better, focused on the needs of each patient regardless of cost, reviewing laboratory and imaging studies with their own eyes, without depending on others.
- The only way to achieve high quality is to adopt high personal standards.
Most of the doctors who have been and are the “rainmakers” at ABC Medical Center, at other private hospitals, and the best Federal Health Institutes and Hospitals, are men educated under these premises.
Medicine in recent decades has evolved a lot and, thanks to that evolution, today it is possible to diagnose and treat diseases that were previously unknown or even when known, science had not advanced enough to treat them and/or provide an adequate quality of life to the patient.
However, these great advances have brought great complexity to treatments, since a great deal of knowledge has been generated and, therefore, specialties and subspecialties have been created within medicine, which, together with the increase in the age of patients and therefore their co-morbidity, cause us to receive older patients and with diverse co-morbidity; that is, more complex patients and therefore have to be seen by many doctors. All of the above, associated with a large technological component as a diagnostic and treatment tool and the excessive cost of some medications, has increased care costs significantly for many years, leading to a borderline situation that is not always fair for the patient and its payer.
The way doctors were educated in medical schools has not changed and does not fit the reality described above.
We need to train a new generation of doctors. In the same article, Thomas Lee talks about some relevant topics:
“Performance matters”: the critical measure can no longer be just how many patients each doctor sees individually or how many procedures they perform, what should matter is the result. In addition, these results must be able to be compared with cases of similar patients. Therefore, to have adequate statistics, it is necessary to change the “art” for guides and protocols. Similarly, we must be able to classify each patient’s degree of severity since, depending on this, we will apply the appropriate guide or protocol, and the most important thing, if we really want to be an organization based on the person, with this working method we will be able to inform the patient better about the treatment options, the expected result, and the quality of life that they will lead after applying it.
“Value is not a bad Word”: Michael Porter defines that in medicine “value” means obtaining the best results in the most efficient way possible. As the concept of value is closely related to insurance companies’ payment, it is identified as something negative by doctors and hospitals, however, and understanding that quality divided by cost is not a numerical ratio, what is clear is that measuring the results and their costs will allow us to improve our performance.
“Performance improvements require teamwork”: Working as a team does not come naturally to doctors, particularly in our society. Mexicans are not good at working as a team, we simply have not been educated that way.
To deal with the current situation, it is important to create high-performance work teams and for this, it is necessary to have leaders. Although leadership is something innate in many people, these leaders must also be prepared and know the tools to exercise that leadership positively.
If we accept as a premise that we will have to care for more and more complex patients and that this care requires the participation of several specialists and subspecialists and the need to follow guidelines and/or protocols to obtain a better result efficiently, it is obvious to think that we have to train professionals who are capable of communicating properly, discussing diagnoses and the best treatments for patients, in addition to the fact that these professionals will necessarily have to work in multidisciplinary groups.
The physicians’ obligation to adequately communicate and inform patients and/or their environment is the most important, but not the only one. This communication and teamwork must include those health professionals who participate in patient care and who spend more time at the patient’s side and in communication with their environment than the doctors themselves. I am mainly referring to the nursing staff and also to all those who must be considered as part of the care team since, otherwise, the probability of making mistakes in the care process will be higher.
On December 29, 2010, “The Lancent” published a study prepared by 20 leading academics in the world proposing a transcendental change in doctors’ training. This study was sponsored by the Bill & Melinda Gates Foundation, The Rockefeller Foundation, and The China Medical Board. The results are overwhelming, health professionals’ education for our century must have the following components: it must be Global; that is, doctors must acquire sufficient knowledge to treat diseases in any part of the world since today there are no borders and the high migration rate means that any disease is exported to the whole world. On the other hand, individualism must be replaced by multi-professional practice, abandon the idea of the brave, independent, and self-sufficient hero and replace these values with teamwork that requires humility and recognize that working as a multi-professional group will bring much better results. The “art” of medicine must be replaced by evidence-based medicine, this should not go against the doctor’s clinical judgment, on the contrary, it should promote it, but always with solid scientific bases and with sufficient statistics to support your clinical decisions. And finally, the only thing that strengthens the “The Felxner Report” idea of more than 100 years ago: the urgent need for doctors in training to receive instruction in institutions, since the classroom, although it is necessary in the first years of training, in a profession such as medicine, must be carried out in hospital environments with the great advantage today that much of what was previously practiced in real patients, today can be practiced in robotic and computerized models, thus avoiding iatrogenesis in real patients.
The four generations and gender diversity.
Never before have four generations worked together. Today, due to the increase in life expectancy, we find in hospitals four generations living and working together, people who have been educated in different values, not better or worse, simply different because they belong to different times and were educated in different contexts and realities, with different ways of thinking and values.
The values of traditionalists born before 1944, people over 75 who established modern organizations, are loyalty, respect for authority, and sacrifice, their goal is to create a legacy, they are thrifty and given the time in which they were born are always worried about “the difficult days that may come”; the “Baby-boomers” born until 1964, people over 55 years old, were the driving force of many organizations, they work long hours and very hard, since this has to do with personal value; generation “X”, born until 1977, are independent people, who saw that their parents and uncles had worked 90 hours a week and do not want to look like them, pragmatic, skeptic, and helpful, they focus on three issues: learn and grow, develop skills, and get results, they were early adopters of technology; and finally the Millennials, born until 1998, they breathe technology as it is part of their life, asking them not to use it for a day is like covering their eyes, they see technology not only as a tool, but as life itself, raised and cared for by Baby-boomers, they were involved from a very young age in decision making, their opinions were always sought and listened to, they only respect the authority that proves to be competent.
In addition to the above, the medical profession has increasingly had the participation of women, which in the time of the traditionalists and even in the time of Baby-boomers was an exception, today is very common. This has positively adjusted the behavior within the profession and not because women are better than men or vice versa, simply because diversity models and constructively adjust behavior.
The foregoing forces us to reconfigure medicine worldwide, trying to apply formulas from the 70s or 80s to our current reality is not only absurd but also condemns us to stagnation and perpetuates the health care model’s mistakes. Let’s see the interaction of several generations or the participation of women in medicine as a great opportunity to be the lever of change that we need.
Our daily actions must be developed on solid ethical principles represented in our Values.
The most successful organizations in the world are built on values and goals that serve as a shield and protection against uncertainty and change. These values and objectives allow us to generate a long-term perspective that guides our daily actions, which sometimes requires a sacrifice for the sake of sustainable success.
The strength of our values evokes positive emotions in those of us involved, they stimulate, motivate, and drive self-regulation and peer regulation.
A society run by this kind of logic, by this set of firm values, is made up of people who are seen and treated with respect and trust, as highly qualified professionals, coordinated and integrated into activities that produce new ideas. People committed to short and long-term values and goals, not mere wage earners who are content with the minimum effort, not even robots that can be programmed and commanded to produce high returns[1].
Alejandro Alfonso Díaz
Mexico City, January 29, 2020
