Making change: The Right Care Movement

If you are reading this, you already know there is an epidemic of overuse in health care. Yes, there is underuse too, and this has been the subject of many lobbying and quality improvement initiatives to date. The medical-industrial complex, particularly in the United States, has capitalized on the fears of individuals who worry they might be victims of underuse, to the tune of billions in unnecessary and harmful "just to be sure" testing, medications, and procedures.

Of course the health of individuals and populations is primary, but we cannot discuss this in isolation, without due attention to cost and sustainability. Given the finite resources we have in health care, we can't afford to throw away the precious time of patients and clinicians, or the money of patients and taxpayers. The best way to fix either problem is to see them – under- and over-use – as one. We need the right amount of care.

Who doesn't dream of a problem in which all you have to do is shuffle the deck to solve it!? This resonates strongly with my predisposition (and tiny amount of training) with Integrative Thinking.

The classic example of two sisters splitting an orange is a good illustration of the potential of integrative bargaining, as well as its elusiveness (Follett, 1940). Two sisters both want an orange, and they compromise by cutting the orange in half. What they would have discovered had they discussed it, however, is that one sister wanted the pulp for juice, and the other wanted the peel for a cake. Discovering that they each wanted different aspects of the orange would have helped the sisters to split the orange in a way that each gets the most individual utility out of the agreement
– Kirk D, Oettingen G. Gollwitzer, PM. (2011). Mental contrasting promotes integrative bargaining. International Journal of Conflict Management, 22(4), 324-341.

This is not a traditional way of thinking. The idea that "less" can lead to "more" is not intuitive. Some examples may help to illustrate the meaning of this when applied to health:

1.By ordering fewer unneeded tests and consultations for one patient (say, to review their cardiovascular profile), the clinician can instead emphasize and support the role of lifestyle changes and free up the patient's time and energy to exercise (which will improve their health far more than any cholesterol test or drug could).

2. If a patient can stop paying for a medication she doesn't need, she has a better chance of making rent payments that month, decreasing stress and the morbidity associated with homelessness as well as reducing the chance of an adverse event or side effect from medication.

3. If one patient's MRI for a sore knee is cancelled because it was planned to assess for a meniscus tear and is not needed as meniscus surgery is not shown to be effective, then timely access is now an option for another patient who needs that MRI (perhaps they've clinically had a stroke and the CT was normal, so the pattern of pathology on the brain MRI would change the treatment plan to prevent further strokes)

It goes on. However, because many people don't think about the big picture for themselves, their practice, or society as a whole, it can be hard to convince them to consider the 'Less is More' mentality. They may only hear "less" and run screaming.

This is why we need to create a huge swell of support, a cultural shift to make the discussion about overuse and underuse the norm. Jeanne Lenzer explains more about how the Lown Institute is attempting this with the Right Care Alliance in The Backstory—Is US healthcare a frontier for a new civil rights movement?


Tensions Creating Less is More; Quality and Quantity

Per my last post, I just spent a week getting fired up about Integrative Thinking, thanks to the CMA and the Rotman School of Management.

The "Right Care" or "Appropriateness in Medicine" or "Less is More Medicine" movement – whatever you want to call it – is a synthesis of the tensions in the healthcare system that exist between the system's needs and the patients' needs. There are common goals, and even tensions between those, eg. between high quality care and a minimally disruptive process, between an efficient system and comprehensive services, between sustainability and quality, and between patient empowerment and provider accountability.

It is possible to have the "best of both worlds," but it is going to take a lot of work to figure out how to get there. Less is More begins by challenging the assumption that "More is Better." By accepting that quality and quantity are not inextricably linked, we open up a world of possibilities for the future of healthcare in Canada. Unsurprisingly, quality and quantity are often at odds for patients who are in their final years, which means that the "less is more" approach often naturally arises in end-of-life care.

In math class as a a kid, I always liked to solve a problem and then do the problem in reverse, to make sure my answer was right. Thinking about "appropriateness in medicine" I realized that maybe we already do have the solution. If I work backwards, will it ensure it's the 'right answer'? Or at least, one possible solution? Can we integrate High Quantity Care with Low Quantity Care to create the Right CareCan quality and quantity be reconciled for something in between, like the "just right bowl" of porridge that Goldilocks found?

The current, unsustainable and ineffective state of healthcare is in part due to the pathological thinking that arises from funding quantity rather than quality of care. By incentivizing disease rather than health care, it's no wonder cost are soaring and health outcomes are slipping. However, it is exceedingly difficult to measure quality, as we've yet to agree on a definition. One idea are QALYs, Quality-Adjusted Life Years, but this measure is not without issue.

If we pick the wrong measure, "payment for performance" models could also lead us astray. This year, we've learned that high patient satisfaction is correlated with increased morbidity and mortality. So, even though institutions and careers were made with this measure, giving patients what they want is not actually in the interest of their health!

There are many options:

-  Performance Measures: find useful quality measures, and create methods for measuring physician/nurse/system/etc. performance; make it auditable, provide feedback, unlicense those whose practices deviate significantly. This is scary for doctors because it diminishes our autonomy, something we value greatly, but it could lead to better access, quality, and efficacy. It may be quite a challenge since patients are ultimately responsible for their health. No matter what a nurse or physician does, there is a lot of the patient's health that is beyond the healthcare provider's control. As well it should be, since we ought to be shifting away from paternalism to patient-centred care, where people take ownership for their health and partner with experts who can guide them along the way.

- Bundled payments: where providers get a lump sum for the handling of one process (eg. hip replacement: it would include pre-, intra- and post-operative recovery including management of complications). Given a lump sum, the team would be motivated to provide the best care, which likely entails shorter stay, fewer medications, better quality surgery, best outcomes, etc. If they manage to save a lot of money by making the care efficient and effective, they profit. If they do a bad job, it costs the providers - not the system. This model provides a disincentive for unnecessary care, but doesn't allow for a lot of self-direction. Special consideration would be needed to account for more challenging patient populations.

- One price per patient per year: no matter how well or sick the individual, the system would have a fixed amount to care for them. This encourages providers to emphasize and support preventative health measures, and to use tests/treatments judiciously. For example, a practice would probably elect to follow Evidence-Based practices that show high value and efficacy. For example, doing colon cancer screening (a small cost) will allow detection and treatment of colon cancer at a time where it would be cost-efficient as well as in the best interests of the patient to intervene; if you don't screen, you find the colon cancer later and it is harder and more expensive to treat. Difficulties? It would take a long time to bear out successes. Also, the sickest patients might never find physicians. Also, physicians may have a hard time combating the consumer culture of "more is better" and thus be unable to provide efficient care.

- ?? More

I have a lot more reading and thinking and integrating to do. The next steps for me involve seeking out more opposing points of view, and to find those, I just have to talk to more and more people about these ideas and hope that I find lots of conflict and disagreement.

Transforming the Canadian Healthcare System with Integrative Thinking

I had the incredible privilege of participating in the inaugural class of a partnership between the Canadian Medical Association (CMA), the Provincial and Territorial Medical Associations (PTMAs), and the Rotman School of Management (University of Toronto).

Forty physician leaders from across the country are spending a week together, learning about Integrative Thinking and its application to Transforming the Canadian Health Care System.

My experience:

- 1 week in a room with 40 flabbergastingly amazing physician leaders from across the country
- Values: we all want to achieve the same things for patients, have similar values, and all have different ways to do it; some have tried and failed, some have succeeded, others are not sure where to start
- Focus: on how to radically transform health care in Canada using Integrative Thinking
- Experts: Rotman School of Management geniuses, the earnest and persuasive Brian Golden & the engaging and hilarious Jennifer Riel, as well as conflict superstar Janice Stein (who I remember watching on TVO as a teenager). Also "Outside Voices" representing PTMA leadership/government, with a call to action from a peer leader.
- Background: the history of the technique of Integrated Thinking is nebulous, but in interviews, Roger Martin identified it as the common strategy used by many successful leaders use to work through impossible or "wicked" problems. It may be rooted in elements of Hegelian dialectic and is highlighted in F. Scott Fitzgerald's writing:

The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function. One should, for example, be able to see things as hopeless and yet be determined to make them otherwise.
— F. Scott Fitzgerald

- Technique: cracking the unsolvable problem by changing the rules, addressing assumptions, and employing the tension between two opposing models to create a third, better answer. And there are many of these better answers, never just one.

The Rotman School of Management defines integrative thinking as:

"the ability to constructively face the tensions of opposing models, and instead of choosing one at the expense of the other, generating a creative resolution of the tension in the form of a new model that contains elements of the individual models, but is superior to each . . .

Integrative thinkers build models rather than choose between them . . .  they creatively resolve tensions without making costly trade-offs, turning challenges into opportunities."

- Variations:

  1. weaving best elements of conflicting solutions together to make a better hybrid (HIDDEN GEM)
  2.  stretching or bending one model in a way that it can produce the best aspects of the opposing model (DOUBLE DOWN)
  3. re-framing the problem, taking smaller elements of it or changing the underlying problem (DECOMPOSITION)

- Examples: Double down integration

Wal-Mart Stores Inc. is an example, when the company thought it had to choose between protecting the environment or protecting the bottom line. Under attack from sustainability critics, the retailer doubled down, using its strong influence on its supply chain to push suppliers into greater sustainability without raising its overall costs.

Read more in this handy summary, "Melding two thoughts to find the best approach," in the Globe and Mail; the original article is "Integrative Thinking in Three Ways." I could not find a free version but if you have a subscription you can read it in the Harvard Business Review.


- Our Example: Our group had to design an acute care system that could get the best of patient empowerment and physician accountability. We designed an emergency room flow that had various points at which self-directed patients could enter or exit the system, with an advocate or medical expert able to guide them at each step along the way.

We could have easily suggested Shared Decision Making where providers and patients work together to make decisions at every step (Variation 1), a totally patient-responsible system that somehow managed to uphold and employ physician guidance & expertise (Variation 2), or suggested that patient-directed care would be in some settings and paternalistic (provider-dictated) care would apply in others (eg. in an emergency, where the patient cannot be consulted) (Variation 3, kind of).
Frankly our rough solution seemed to involve elements of each approach. As a group member said, "we gave the patient a paddle instead of sending them down the creek (of acute care) without one."

Other considerations in the process:
- reconsider 'opponents' in negotiation as partners in creative problem solving; you probably share common goals (eg. both government and physicians want good quality healthcare for patients); working with those in mind will help create a win for everyone
- slow down, take a step back, and think about the needs you are addressing and challenge all assumptions before jumping to a solution
- know the people that you are representing and frequently share with them and seek their input
- create an institutional culture where conflicting ideas are embraced and used to make the projects and product better; encourage this with techniques like a rotating Devil's Advocate, focusing on common goals and values, and not forgetting about the psychology of political intelligence (which we learned through watching 12 Angry Men)

How does this relate to Less is More?

I assure you, it relates entirely! Furthermore, learning about Integrative thinking has allowed me to take a step back and look at the underlying needs, tensions, and to work through to some solutions. Plus, I need to round up some opposing viewpoints, because people who challenge the idea are my new best friends (for creating change)!

Stay tuned for the next post.