The Donut, Not the Hole

Albert Einstein once said that “We cannot solve our problems with the same thinking we used when we created them.”  The long-run challenge in healthcare is not about becoming incrementally better.  Getting faster and more accurate, committing fewer errors are all important.  But that is the expectation.  In the long run, to be successful we need to challenge preconceived ideas and do things differently.  This is not about squeezing a percentage point or two out of productivity, but redefining what productivity means.  Or as noted author and entrepreneur Seth Godin has said, “Change is not a threat, it’s an opportunity.  Survival is not the goal, transformative success is.”  Survival should not be our goal; transformation should be.  This means that we won’t be successful simply by hiring three more doctors or building a couple of new clinics.  Don’t get me wrong, these may be important to survival and to better managing the community’s needs, but these things are not transformative. 

I lived in Southern California for a few years and therefore spent some part of my life in gridlocked traffic.  When I lived there, most of the infrastructure plans to address gridlock involved adding another lane to existing highways, or building completely new highways connecting two new points, or converting an existing lane to a high occupancy vehicle (HOV) lane.  While I could see how this seemed like the easiest ways to improve flow, I also could see how these would not help at all.  When traffic is at a standstill, it is difficult to understand how an extra lane would have traffic moving faster.  Further, there were already HOV lanes in Southern California that only required TWO passengers and they were mostly empty. 

The solution to Southern California traffic isn’t more of the same.  It is rethinking the entire process to begin with.  This means both addressing the supply and the demand.  We can build all the bullet trains we want, but if they travel empty, what have we done?  We can encourage people to use mass transit, but if it doesn’t take people where they want to go when they want to get there, it has no value.  What ends up happening is a vicious cycle where the lack of infrastructure leads to lack of demand which justifies the lack of infrastructure.  But the real reason that this fails is because no one has articulated a GOAL that all can work towards.  If we cannot inspire people to chase a goal, then the rest really doesn’t matter. 

Modern healthcare is built much like the modern highway system.  We layer more of the same on top of the infrastructure and don’t discuss any of our goals that have not changed in eighty years.  Adding more nurses or doctors is like adding another lane on the freeway.  Worse, since many doctors a system adds are merely poached from private practice or other health systems, you are really not building new lanes but perhaps converting lanes to HOV.¹ 

Let me break down the math of “more of the same.”  Depending on who you ask, anywhere from 80 to 100 million Americans do not currently have a primary care provider.  The average patient panel for a primary care doctor varies between 1,200 and 1,900 patients.  Splitting the difference on these ranges, America is currently about 60,000 doctors short of current demand.  Since America produces about 8,000 new doctors a year, it will take over seven years to close this gap.  Or it would, if it weren’t for the fact that about 10,000 doctors retire every year, so we are currently losing 2,000 doctors a year.  Since about 30% of physicians are above the age of 60, one would expect that the retirement number will climb in the coming years.

All these numbers are broad estimates, and this is all simple math.  The point of this calculation is simple to prove Einstein’s point.  We will not solve our problem using the same model that created our problem.  We cannot fix the problem by simply providing more of the same.  Before you start trying to read subtext, this is NOT an essay about the evils of insurance, the greed of doctors, or how we need to switch to some other payment plan.  Lower your defense shields; put your hackles down.

The essay is about how to encourage more alternate solutions to current problems.  Broad, systematic changes may be needed, but just like the SoCal traffic, those solutions will take time, energy, buy-in, and vision.  In the meantime, we have people without doctors and chronic conditions that are not being adequately served.

About a decade ago, Cleveland Clinics and other systems instituted shared medical appointments (SMA) to manage demand.  The concept here is that clinicians can meet with multiple patients with similar needs at the same time.  So, patients with diabetes, heart disease, osteoporosis, chronic pain, or prenatal care can meet with a provider collectively.  Some will call it a “support group,” but I find this term diminishes or trivializes the work done since these groups are led by doctors and involve medical care.²

These SMAs have been shown to improve patient outcomes and patient satisfaction³ by improving access as well as creating a sense of camaraderie among patients all battling the same issue.  They can also improve perception of time-spent while at the same time creating a way for providers to see more patients in less time.  Meanwhile, providers can reduce the times they have to answer the same question or provide the same guidance.  Their schedules then allow for timely appointments with patients who need specialized attention.  So, it is a rare confluence of positive experiences and positive outcomes. 

If you are reading this and know all about SMAs, well, congratulations!  You are one of the few who have heard of them.  From 2005 to 2015, this model went from being offered by about 5% of providers to being offered by almost 15% of providers.⁴  Now, rough estimates indicate that as many as 20% to 25% of providers offer it.  So, in twenty years, we have seen the numbers rocket up from a tiny minority to a small minority.  Certainly, COVID impacted its implementation just as it did with joint camps and birthing classes.  But why haven’t we seen more widespread adoption of this model?  Heck, if it reduces costs and improves outcomes, why haven’t we seen insurance plans require it? 

Just like mass transit, this requires an effort to break the vicious cycle.  Let us look at the supply and the demand. 

• If you build it, will the patients come?  I will leave it to others to opine whether it is learned or innate, but patients have an expectation of privacy, especially in healthcare concerns.  Encouraging them to meet with eight or nine other strangers who share the same affliction may breed kinship and better outcomes, only if you can convince them to show up and share.  Otherwise, this value will seem nonexistent compared to their fear of judgement and shame.  This is without even addressing the stereotypes of rural or elderly patients (who would likely benefit from this approach more than most) who have a clear expectation of what the relationship with their provider and privacy looks like.
• If you build it, will the physicians come?  Much like the patients, doctors may complain about the current scheduling nightmares but are also going to be suspicious of this solution.  Meeting with ten diabetes patients for 90 minutes is more time-efficient than meeting each one in-turn for twenty minutes.  But that savings of 110 minutes does not account for the time reviewing charts before the meeting and charting after the meeting.  Likewise, while it may provide value, providers might only see the possibility that one domineering patient will drown out the other patients.  They may not want to run a “focus group” on cardiac care.

Moreover, the value of this process is not evenly distributed.  For those who don’t have consistent access to a primary care provider, this will seem ideal.  For others, though, this will feel like a demotion, where the patient’s ME-time with a provider get supplanted with US-time.  From a structural perspective, it also has challenges.  Scheduling can no longer simply give a patient a laundry list of potential appointment times and let them pick what they want, even if it is six weeks out.  Now schedulers must work with patients and providers to find a suitable time that works for everyone.  I am not even going to touch the whole relative value unit (RVU) issue, which is how CMS determines how to compensate for services.  Without a vision that will inspire patients and doctors, then, this entire process will continue to wobble unevenly along.  Perhaps in another twenty years we can push up the percentage of providers providing this service to forty percent!  You can come to my gravesite to tell me all about it.

Please do not mistake the realism of this essay for pessimism.  It is only to inform you that there is a level of inertia inherent in any system that must be addressed.  There is a reason why, whenever I train people in patient experience, I first focus on the vision and second focus on the self-interest in the audience.  If I jump right into hourly rounding or bedside shift reports without doing the prep-work, I will be treated with disinterest if not outright hostility.  Heck, even with that work, I will still encounter some of those responses. 

I am startled by how often I read about organizations trying things that seem silly at the outset and simple once someone else tries and succeeds at them.  It seems the real challenge is not that these efforts are made, but how easy it is for many to discard or discount these efforts.  Contrary to popular opinion, innovative ideas are not scarce and coming up with them is not difficult.  Getting those ideas through the gauntlet of skepticism and dismissal is the difficult part.  You have all heard the deflections:

• Yes, well, with unlimited resources we could all do those things.
• You can show anything is true with statistics.
• They don’t have the same challenges we have.

Or my personal favorite

• We tried that and it didn’t work.

It is not that people like the status quo, but that they are conditioned to focus on the hole and not the donut.  We are told so often that “failure is not an option” that we don’t even try.  This is also why many people’s first response to a new idea is to discuss the reasons that it won’t work rather than the benefits of it working.  I will admit that my first thought at group sessions for diabetes patients in Cleveland was that this would never work.  I thought of the dozen ways this would crash and burn.  But I realized that the goal was critical not just for patients’ well-being, but for the organization’s survival.  So instead of focusing on how silly it was, I should be focusing on how it can be used to serve our patient population.

All of this leads to the biggest vicious circle of them all.  During COVID, many health systems ran yearly deficits, expecting that things would return to normal and the balance sheets would fix themselves.  The pandemic broke, but the toothpaste did not return to the tube, and they were put on the horns of a dilemma.  They need to redesign key elements of care, even as they have, at best, razor-thin profit margins.  In other words, they needed to take risks even as they were risk adverse.  If systems want to climb out of this hole, they need to first do something both counterintuitive and critical: they need to stop punishing their team for swings-and-misses.  An organization cannot be both (a) critical of staff for not being proactive and (b) beating on their staff for failures.  Scratch that, a RATIONAL organization cannot do that.  I will leave it to the reader to determine if they work at a rational organization or not. 

Regardless of corporate culture, though, I would encourage you to push yourself to keep trying, if only for your own professional mental health.  One of my favorite quotes also comes from Seth Godin.  I had it posted on my wall in my old office: “Persistence isn’t using the same tactics over and over.  That is just annoying.  Persistence is having the same goal over and over.”  Without the goal, the rest is just pestering.  So, I ask: what is your goal?

¹OK, I will abandon this metaphor now, as it has become unwieldy. 

²I also don’t mean to diminish the value that support groups have.  Support groups save lives.  The real point I am making is that the phrase comes with some emotional baggage and is used by some who wish to minimize the value of self-help in their toughen-up world view.

³Someday I will launch into an essay on how self-selection can inflate early successes.  But not today.  Today, I will blithely embrace that success occurred. 

⁴Or, as one article referenced it, “a 300% increase!”  Oh, how I love math.