Thursday, February 12, 2009

Check out Dr. James Mountford's latest work

When clinicians lead, published in The McKinsey Quarterly. A brilliant piece, well worth reading by Mountford and Webb.


  1. I could not agree more with Dr. Mountford!! It is critical to get clinicians into the policy making process.

    However, the impediments to this change are very significant--as discussed in the article (i.e., clinician skepticism, negative career incentives, and a paucity of mentors).

    An additional impediment is more subtle, and much more problematic in my opinion. That additional impediment is the coldly calculated self interest of "organized medicine" (i.e., physician interest groups on the national and local level). These groups are not interested, as a whole, in changes to the health care system that do not result in more revenue for their members--whether or not the changes are better for patients.

    In the US, we should always remember that Medicare was originally proposed by President Truman in 1945 as a universal coverage initiative. "Organized medicine" killed that initiative to guarantee coverage and turned the system into a "guaranteed payment" program. At a time when other countries (like the UK) were creating health care systems that recognized the need to treat health care as a human right, the US was more interested in the reimbursement of physicians.

    So, a very intense cultural impediment to clinician leadership is the risk of being "thrown out of the club" for advocating for systems that work for patients but not for doctors.....

  2. You are right on in your assessment, Dr. Smith, about self-intrest as the primary thwart to "righteous" health care. May I take this a step further into the specific and suggest that it is high time that physicians everywhere lose the man-made idea of "The Week-end?" The day of the week has no relevance in health care. You know the list of job titles in which there exists a committment to work weekends. Physicians, specialists, all surgeons, etc. ought not be able to cite a particular day of the week as a reason for not working. And yet, this is exactly what happens on 52 Fridays a year to those who are unfortunate enough to be admitted to any hospital that day of the week. Or, in an alternative vignette, if that's the day of the week it was determined that you needed such-and-such a procedure that "can't be done until Monday." Am I wrong to believe that this organization around the week-end accounts for, at the least, two days of stasis re: length of hospital stay? Can we afford this whimsical arrangement, created as the Industrial Revolution progressed, to be maintained nowadays in the realm of health care, which we agree is a right for all? Do Doctors Without Borders personnel out there in the world "take off" every weekend?
    I think we have, for those who can afford it, a good health care system, and just the existence of this blog site lets me know that there are those who seek to improve on all the good things we've got. I propose that nationally you physicians that work in clinics and for nursing homes and for public health and in the acute care setting look forward to adding committment to working weekends as part of your chosen profession. And do not hand out a "weekends off" benefit for any reason. This is not patient centered health care. I wonder what the change in medical school applications would be if school children grew up knowing that to be a doctor would mean committing to weekend work the whole of your career. Full surgery schedules on both Saturday and Sunday, as well as clinic hours at the same availabilty as weekdays... what a concept! Would it improve outcomes? Would it reduce ER visits due to timely intervention at a clinic visit? Whom would it inconvenience except a physician (maybe a technician's? Really and truly, Dr. Smith, if you'd like to pay it forward, hatch this idea to the medical profession as a whole. We nurses "pilot" programs on our acute care units rather often. Can a county entity pilot such a program eliminating the weekend days of the week as static days and begin a "putting your money where your mouth is" posture of full availability of services seven days a week? Would the medical profession defend such a thing? Would physicians come to respect even the idea that weekend days off may belong to other professions, but not theirs? As do nurses, caregivers, housekeepers, firefighters, police, etc. (the list I mentioned above, which you already know).
    Please consider this idea as relevant to the mission statement of CCCRMC.
    Mary List, RN, MSN

  3. Mary, I believe that you are very correct. Our national system of health care is really not "patient centered." Although I am certain that many individuals would debate that assessment, the final outcome makes the reality quite clear. Spending more on health care, we have poor public health outcome measures--that is all that it boils down to.

    As for your argument about weekends, I also agree. There is no good patient care reason for weekends to be treated differently than weekdays.

  4. James Mountford17 April, 2009 22:50

    Anna: thank you for highlighting the article on your blog. It's prompted me to have a good look at the blog -- you write beautifully (and often movingly) about fascinating and important topics. I will return often!

    To Jeff and Mary's interesting comments: I agree aligning the incentives for physicians (and, I'd add, of organizations) with those which will best serve patients' and the public interests is critical. If this is to be the year for healthcare reform in US, doing this will need to be front and center if it's to be successful. A striking example of misalignment is a payment system under which the 'reward' for keeping someone with a longterm condition as healthy as possible is reduced provider income.

    I think that creating this alignment, and then ensuring that those who perform best (in terms of delivering high quality, efficient care) prosper will be one of the most important pillars in building clinically-led services. Because healthcare's too complex to get high quality and efficiency without having the key technical experts --the clinicians-- at the heart of the decision-making about how to design and run services.