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The Complexity Matters blog features the Thursday Complexity Post as well as other complexity inspired news items.


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Some Gene Mutations Are Good

Posted By Prucia Buscell, Thursday, January 1, 2015
Updated: Monday, January 5, 2015

For years, researchers have looked for gene mutations that cause disease. Two scientists who started The Resilience Project have flipped that effort upside down and started looking for gene mutations that protect against disease. Discovery of such positively deviant genes paves the way for drugs that mimic the protective qualities.

A New York Times story by Gina Kolata tells the story of a Port Orchard, Washington, man who has a gene for early onset Alzheimer's. The man's older brother, mother, nine of his mother's siblings, and six cousins began showing symptoms in their 40s, and most died in their 50s. The man, now 65, has no signs of the illness, and researchers are trying to learn whether he has a genetic mutation that is counteracting or substantially delaying the horrifying impact of the Alzheimer's gene that he has.

"Instead of trying to fix things that are broken, let's look at people where things are broken but nature finds a way around it," Dr. Eric E. Schadt, director of the Icahn Institute, a medical research institute at Mount Sinai Hospital in New York, said in an interview with the Times.

Researchers have found many gene mutations that cause disease or predispose a person to an illness, and those seem to be considerably more common than the beneficial mutations. However, with today's fast and relatively inexpensive methods of sequencing DNA, and the ever-growing databases of study subjects whose genomes have been sequenced, scientists can begin to look for the positive mutations. Dr. Schadt and Dr. Stephen H. Friend, director of Sage Bionetworks, a nonprofit research organization in Seattle, are searching databases that hold clinical and genetic information. They are looking for people who, despite having mutations for fatal diseases that strike early in life, have remained healthy far past the age when the illness should have appeared. They have analyzed data from more than 500,000 people, and found only 20 in which a good gene mutation appears to have blocked a bad one. But because no names are attached to the data, the scientists can't contact those people. So they contacted researchers studying extended families with severe genetic illnesses, and they found the Washington man.

Some amazing beneficial gene mutations have already been discovered. One prevents HIV from entering cells and causing AIDS, and that discovery has enabled scientists to treat HIV positive patients by directly editing their cells. Discovery of another gene alteration that prevents build up of LDL cholesterol led to discovery of a drug that is now in the final stage of testing. Researchers using genetic databases have also found mutations in some genes that confer partial protection against heart disease, osteoporosis and Type 2 diabetes.

The Washington man who seems to have defied his dangerous Alzheimer's gene retired recently. He told the Times his life's work now is to help scientists understand the treacherous disease that claimed the lives of so many members of his family.

Tags:  buscell  complexity matters  health  positive deviance  research 

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It’s Not Unusual

Posted By Jeff Cohn, Wednesday, July 9, 2014
Updated: Friday, September 19, 2014

Jasper Palmer died last week. He was a patient transporter at Einstein Medical Center in Philadelphia for more than 20 years. Jasper and I became connected closely in 2005 when Einstein became a participant in the Positive Deviance/MRSA project, facilitated by Plexus Institute. The role of the patient transporter is to do just that: transport patients throughout the medical complex to wherever they need to go. When that patient is identified as harboring the "superbug" MRSA, preventing the bacteria from spreading during that transport is quite a challenge, one that even experts from the CDC hadn’t figured out. We recognized that working with the transporters and asking them how to transport MRSA-positive patients could uncover solutions and barriers of which we weren’t aware.

Jasper emerged as a leader when he pointed out a significant barrier to safe contact with these patients. MRSA-positive patients are placed in "contact isolation,” meaning that staff entering their rooms are required to put on gowns and gloves prior to entry. Jasper noted that trash cans were often overflowing with gowns that had been worn and disposed. This left the next person entering with a dilemma - does one do the right thing by wearing a gown, only to have no reasonable place to dispose it? Or does one avoid the disposal problem, take a risk, and perform the patient task without a gown? Not only did Jasper identify the challenge, he developed a solution that worked for him that could work for others. See him demonstrate his simple solution in the video.

Given a forum to share his concerns and solution, Jasper took it upon himself to help others learn this approach. He would stop physicians facing the disposal dilemma and tell them, "I think I have a method that could help.” He worked with his transport colleagues to develop safer methods of transporting patients, even those connected to ventilators and monitors. Not everyone adopted the Palmer Method. However, it garnered attention to the challenge and ultimately investments were made in different disposal apparatus that could accommodate the large volume of gowns being disposed much more effectively than the small, rigid trash cans in place before.

We wound up referring to Jasper as an "unusual suspect.” By this we meant he wasn't a typical infection prevention expert (i.e., physician, nurse, pharmacist). We learned that we needed to look beyond the usual suspect to those unusual ones, from which diverse perspectives and new innovations would emerge. Instead of asking, "whom do we need to involve?” we asked, "who doesn’t need to be involved?” and then tried to engage everyone else.

Upon learning of Jasper's death, I began to think about the concept of unusual suspects. On reflection, it strikes me as, while well intentioned, a bit demeaning and indicative of our fixation with hierarchy and position. Jasper had served his country in the military, was a family man, had worked at Einstein for many years, had lots of friends, and cared about patients. Why wouldn’t we think someone like him could be beneficial to our improvement efforts? Using this lens, who would qualify as someone unlikely to be a source of new behaviors and ideas, an unusual suspect? Someone wedded to the status quo? No, there are likely many benefits of the current state that deserve preservation. A skeptic? No, their contrary position can help expose blind spots. Maybe a good example is a content expert who is unwilling/unable to see any other perspectives. In the case of our MRSA work, those would typically be clinicians and the same people we initially thought would be our key contacts.

Jasper, I think you've taught us all a critical lesson. Anyone- no, everyone who cares about a challenge, who wants to be involved in any way, and who is willing to share collaboratively can be a useful contributor. In fact, we depend on the diverse perspectives of many to discover and create the solutions for our big challenges. Thank you, Jasper, for helping us to appreciate the wisdom that lies within our networks. Your legacy will live on through the work we and others you've touched carry forward.

Tags:  catching butterflies  cohn  healthcare  positive deviance  relationships 

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Conversation, Engagement and Front-Line Ownership

Posted By Prucia Buscell, Thursday, April 18, 2013
Updated: Wednesday, April 17, 2013
Everyone can learn processes to generate and maintain organizational change. Organizational achievements can blossom when everyone is engaged. Safety culture in hospitals flourishes when front line staff members take ownership of safety issues.

Three articles by people affiliated with Plexus Institute examine how these ideas can benefit organizations and the people they serve.

Lisa Kimball's article, "Changing the Organization One Conversation at a Time," (pdf) describes processes that help facilitate productive large group meetings, intervene in whole systems, and maintain the enthusiasm that emerges from provocative discussions in newly formed relationships. Liberating Structures (LS), for instance, form a framework for designing processes that support high quality conversations. The structures are easy to learn and their use can promote creativity and engagement, not only at meetings but when people return to their daily routines. Lisa describes them as "Lego-like components that can be mixed and matched" for use anywhere people gather. The payoff, she said, comes when the use of these helpful processes becomes so widely distributed that it is the norm rather than the exception. Some useful LS processes include wicked questions, silence, and 15 percent solutions.

Questions are "wicked" when tension and paradox are embedded. There are no obvious solutions, and no right or wrong answers. Wicked questions expose assumptions and elicit new ideas. An example might be: How can we maintain top-down discipline needed for safety at the same time we level the playing field for bottom-up creativity? A brief silence creates a boundary between past activities and the present phase of a discussion, and it's a good reset technique if a discussion is veering off track. Peter Drucker suggested that most people control only about 15 percent of their work situations, and the other 85 percent is shaped by the existing structures, systems, events and culture in their environment. People who make the best use of their own 15 percent can create small changes that have outsized impact. Lisa's article appears in the Spring 2013 issue of the OD Practitioner, the Journal of the Organizational Development Network. Lisa has served as a Plexus Institute trustee and is its former president and CEO.

"More We than Me: Using Positive Deviance to Engage Everyone," (pdf) by Prucia Buscell, appears in the same issue. It describes how people from many departments and different disciplines at the Albert Einstein Healthcare Network in Philadelphia worked together using the Positive Deviance (PD) approach to drastically reducing the incidence of healthcare associated Methicillin Resistant Staphylococcus Aureus
(MRSA) infections. PD is based on the idea that in every community there are individuals or groups who solve problems better than colleagues who have access to the same resources. In healthcare, PD bridges the gap between what care-givers know and what they do. They know infection reduction protocols, but don't always follow them. At Einstein, all individuals in the healthcare environment-physicians, nurses, aides, therapists, housekeepers, and staff in all support services-engaged in the effort to prevent transmission of pathogens that might happen in their own work areas. People from different departments met and collaborated on ways to remove barriers to consistent adherence to known infection control practices. Asked if their achievements could be sustained, several healthcare workers emphatically said "yes." It would last, they insisted, because it was their own process. Prucia is communications director at Plexus Institute.

"Front-Line Ownership: Generating a Cure Mindset for Patient Safety" will appear online April 26th in Healthcare Papers: A New Model for the New Healthcare, Vol. 13, No. 1, 2013. While great advances have been achieved in the field of infection prevention and control, the authors of this article believe even greater progress has been hindered by power gradients, dysfunctional relationships, and lack of "safety mindfulness" in hospital and healthcare environments. One successful approach to these problems, they suggest, is front-line ownership, or FLO. Ownership involves having people who do the work develop ideas for design and implementation of solutions. The authors discuss the logic involved in safety, the need for inter-connectivity to amplify safety efforts, and the importance of context and social proof in developing a safety culture. The underpinnings of the FLO approach, they write, are Positive Deviance, and a complexity science analysis of complex adaptive systems and resilience. Their work also used social network mapping, Liberating Structures and insights from the field of organizational development. Their 18-month study at five Canadian hospitals provided evidence that FLO reduced the combined pathogenic organism rate at study sites and allowed different groups to attain best practices in ways that worked most successfully in their individual settings.

The authors are Brenda Zimmerman, Paige Reason, Liz Rykert, Leah Gitterman, Jennifer Christian and Michael Gardam. Liz is a former Plexus Institute trustee.

Tags:  buscell  complexity matters  engagement  healthcare  positive deviance 

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A Discovery Flutters in the Wake of One Word

Posted By Jeff Cohn, Wednesday, August 8, 2012
Updated: Friday, September 19, 2014

In memory of our friend, Jerry Sternin, PhD

It was nearing the end of a block (a period of time that a physician commits to covering a particular hospital-based service) where a colleague was serving as the attending physician on their hospital’s teaching service (a service that works with physicians-in-training and cares for patients who do not have attending physicians of their own). One of the responsibilities was to evaluate certain physician-in-training skills through observing their interactions with patients. One of the first year residents asked her to watch him provide instructions to a patient being discharged to home. Mr. Johnson had entered the hospital over a week prior, having been admitted in respiratory failure due to emphysema. He had spent several days in the Intensive Care Unit on a ventilator, though he was now nearly back to his baseline status. The resident was convinced that this flare-up was due to Mr. Johnson not correctly taking his medication, and this was going to be the focus of his instructions. For over ten minutes the resident spoke to Mr. Johnson in earnest tones about the importance of taking his medications regularly. He reviewed with Mr. Johnson how to take them reliably, reminding him what could happen (again) if this didn’t occur. Mr. Johnson nodded in agreement; he had clearly been shaken by this hospitalization and didn’t want a recurrence like this in the future.

At one point the resident asked Mr. Johnson to describe how he took his medications. Mr. Johnson replied, "Well, in the morning I usually take them before breakfast. Then I take them with lunch and dinner later in the day.” The resident eventually reached the end of the interaction, provided the written instructions to Mr. Johnson matching those he had spoken about, and he then turned to my colleague. "Do you have any questions for Mr. Johnson?” the resident asked.

"Well,” she said, "I do have just one. Mr. Johnson, I believe I heard you say that you usually take your morning medications before breakfast. When I hear someone say usually, to me that means that sometimes it doesn’t happen that way. Is that correct? What gets in the way of you taking your medications before breakfast?”

Mr. Johnson nodded and gave a sheepish grin. "You know, in addition to having emphysema I also have diabetes. So first thing when I get up I take my insulin. And I know I have to have breakfast within 15 minutes or so or else my sugar will drop and I’ll get sick. Sometimes one of my friends will call me on the phone after I take my insulin but before I take my lung medicines. I’ll talk to him for a while and then I’ll remember I need to eat some breakfast. So I’ll get off the phone with him and make breakfast, and, I guess, some of those times I don’t remember to take my morning lung medicines.”

"So, what ideas do you have as to how to prevent that from happening?” sheasked.

"I guess I should tell my friends that I can’t talk if they call first thing in the morning and that I’ll call them back after I’ve taken my medicines and finished my breakfast- that should do it, I think,” he replied.

When Jerry Sternin of the Positive Deviance Initiative was coaching us years ago about how to facilitate "discovery and action dialogues” to come up with ideas and actions to prevent MRSA infections, he referred to the technique of "catching butterflies.” You need to listen with your whole self, particularly listening for the ideas (the butterflies) that can be converted into concrete actions. By "whole self” I mean being fully committed to experiencing the totality of the conversation- hearing all the words spoken, looking at facial mannerisms and other visual cues that may add meaning to the words, allowing your heart and head to connect with the experience, and being sensitive to your initial spontaneous reactions and perspectives. As the words and ideas are spoken, imagine them to be butterflies floating up. Which ones seem to be actionable? Perhaps the action is for you to ask clarifying questions if something is confusing or doesn’t seem to fit, or maybe there are latent action potentials for the speaker that you can help become explicit. The listener/facilitator gently catches them and holds them up to the individual/group, asking questions like, "What do you think? What could you do next?” In this particular conversation the physician’s goal was to help Mr. Johnson create a reliable process for taking his medications. Reliability implies "always” and so "usually” was the butterfly - a word requiring action. 

Catching butterflies requires the listener to couple an interest in exploration and discovery with a specific goal or outcome. Our focus at Plexus Institute is to translate concepts derived from the science of complex systems into actions so that communities can resolve intractable challenges they’re facing. In my blog I’ll be trying to gently capture stories/concepts and hold them up to the Plexus community, looking to use our collective wisdom to create actions leading to good enough solutions.

Kind of like catching butterflies.

Jeff Cohn, President

Tags:  catching butterflies  cohn  health  positive deviance 

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Inviting Everyone: A New Book from Plexus Institute

Posted By Susan Doherty, Thursday, August 12, 2010
Updated: Thursday, June 6, 2013
Plexus Institute announces the release of "Inviting Everyone: Healing Healthcare through Positive Deviance

This book tells the remarkable story of how a people-centered approach to organizational and social change, accompanied by sound scientific and technical expertise, yielded positive quality outcomes for ordinary citizens, health care institutions and their patients, and society in general. This work draws upon the collective wisdom and experience of infection control practitioners, doctors, public health authorities, nurses, social and organizational change practitioners, health care administrators, patients and front line workers. Additional benefits of use of the PD process to fight infection turned out to be improved workplace relationships, healthier and more resilient organizational cultures, and expanded networks of people in many fields and geographical locations who shared ideas, resources and the inspiration of their own contributions to saving lives.

Tags:  plexus  positive deviance  stopMRSA 

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An Elegant Solution

Posted By Susan Doherty, Thursday, May 27, 2010
Updated: Thursday, June 6, 2013
From JONA, Volume 40, Number 4, pp 150-153, "Positive Deviance: An Elegant Solution to a Complex Problem” by Curt Lindberg and Thomas R. Clancy. Statistics from the partnership hospitals using the innovative PD intervention documented dramatic declines in MRSA infection rates.

Article attached below.

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Tags:  positive deviance  stopMRSA 

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Billings Clinic Cited for High Quality Low Cost Care

Posted By Susan Doherty, Monday, August 17, 2009
Updated: Thursday, June 6, 2013

Billings Clinic

The Billings Clinic was a beta site hospital in the Positive Deviance (PD) MRSA Prevention Partnership, spearheaded by Plexus Institute and funded by The Robert Wood Johnson Foundation. Nicholas Wolter, MD, the CEO of Billings Clinic, was one of the founders of Plexus Institute. From Invisible to Visible: Learning to See and Stop MRSA at Billings Clinic, the story of how the Billings Clinic used PD to reduce MRSA infections by 84 percent, is attached below.

The PBS News Hour with Jim Lehrer has featured the Billings Clinic (video has since been removed) as an example of how high quality health care can be provided at relatively low cost.

In a special segment of the program, aired August 12, health correspondent Betty Ann Bowser visits the clinic, in Billings, Montana, and talks to doctors about the clinic’s model of integrated patient care and clinic’s participation in a Medicare project designed to reduce costs and improve patient outcomes. The segment opens with President Obama citing the Mayo Clinic and the Cleveland Clinic as examples of providers of high quality and lower cost care, and asks the question: what are they doing that’s different?

Billings, which is modeled after the Mayo Clinic, is introduced as another facility that is doing differently, and better. With 3,500 employees, it is the largest multi-specialty medical group practice in the state, and treats 148,000 patients annually at a dozen locations. Physicians at Billings, even the high end specialists, are employees who are paid a salary, rather than working as independent contractors. Dr. Doug Carr, medical director, says that means doctors are paid for care of patients, without regard to the type of insurance reimbursement the patient has or the number of tests ordered.

Two years into the Medicare project, the average annual expenditure per Medicare patient at Billings is $6,332, well below the national average of $8,304. Dr. Carr says coordinated care, including the benefits of a telemedicine program for patients at a distance, saved $1.5million in avoided hospitalizations.

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Tags:  health  positive deviance  stopMRSA 

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Billings Clinic: High Quality Care at Lower Cost

Posted By Prucia Buscell, Thursday, August 13, 2009
Updated: Thursday, February 17, 2011
The PBS News Hour with Jim Lehrer has featured the Billings Clinic as an example of how high quality health care can be provided at relatively low cost.

In a special segment of the program, aired August 12, health correspondent Betty Ann Bowser visits the clinic, in Billings, Montana, and talks to doctors about the clinic's model of integrated patient care and clinic's participation in a Medicare project designed to reduce costs and improve patient outcomes. The segment opens with President Obama citing the Mayo Clinic and the Cleveland Clinic as examples of providers of high quality and lower cost care, and asks the question: what are they doing that's different?

Billings, which is modeled after the Mayo Clinic, is introduced as another facility that is doing differently, and better. With 3,500 employees, it is the largest multi-specialty medical group practice in the state, and treats 148,000 patients annually at a dozen locations. Physicians at Billings, even the high end specialists, are employees who are paid a salary, rather than working as independent contractors. Dr. Doug Carr, medical director, says that means doctors are paid for what they do forpatients, without regard to the type of insurance reimbursement the patient has or the number of tests ordered.

Two years into the Medicare project, the average annual expenditure per Medicare patient at Billings is $6,332, well below the national average of $8,304. Dr. Carr says coordinated care, including the benefits of a telemedicine program for patients at a distance, saved $1.5million in avoided hospitalizations.

The Billings Clinic was a beta site hospital in the Positive Deviance (PD) Methicillin resistant Staphylococcus aureus (MRSA) Prevention Partnership, spearheaded by Plexus Institute and funded by The Robert Wood Johnson Foundation. Nicholas Wolter, MD, the CEO of Billings Clinic, was one of the founders of Plexus Institute. From Invisible to Visible: Learning to See and Stop MRSA at Billings Clinic, the story of how the Billings Clinic used PD to reduce MRSA infections by 84 percent, is available at the Plexus Institute website in the e-library.

Tags:  buscell  complexity matters  healthcare  MRSA  positive deviance 

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MRSA and positive deviance

Posted By Susan Doherty, Friday, June 26, 2009
Updated: Thursday, June 6, 2013
Curt Lindberg, Plexus Institute’s chief learning and research officer, is quoted in the June 2009 issue of Briefings on Infection Control published by HCPro, Inc. Curt discusses the impact of using the Positive Deviance method in hospitals.

"[sites that participated in the Positive Deviance MRSA Prevention Partnership] were very interested in the methodology because they had all tried many of the typical and standard approaches to improving quality and MRSA prevention and were not seeing really good results from those efforts, so they were kind of frustrated and open to new approaches.”

"[Frontline staff] are the ones that have contact with patients and families, and are in and out of rooms, and are moving equipment around, so they know what’s going on, and it’s their actions and behaviors that directly affect infections and infection prevention.”

Tags:  MRSA  positive deviance  stopMRSA 

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Dr Atul Gawande on Jerry Sternin

Posted By Susan Doherty, Tuesday, June 16, 2009
Updated: Thursday, June 6, 2013
These are excerpts from Atul Gawande’s commencement address to graduating medical students. Dr. Gawande has been a fan of the PD approach for sometime and a personal friend of Jerry and Monique Sternon as well….

J SterninJerry Sternin died December 11, 2008. He would have had his 71st birthday this June 14. Monique Sternin, his widow and partner in pioneering Positive Deniance, shared this speech and asks those who knew Jerry to join in celebrating his life and work.  

Atul Gawande Calls On New Doctors to Fight for the Soul of Medicine
Dr. Atul Gawande addressed students graduating from the University of Chicago’s Pritzker School of Medicine, calling on them to join in the "battle for the soul of medicine.” Unlike many who say "we must do something,” he offered some very specific examples of how doctors can "resist the tendency to see patients as a revenue stream.”

Below, excerpts from his June 12 address:
.” . . I want to tell you the story of a friend I lost to lung cancer this year. Jerry Sternin was a professor of nutrition at Tufts University, and with his wife, Monique, he’d spent much of his career trying to reduce hunger and starvation in the world. He was for awhile the director of a Save the Children program to reduce malnutrition in poor Vietnamese villages. The usual methods involved bringing in outside experts to analyze the situation followed by food and agriculture techniques from elsewhere.

The program, however, had itself become starved—of money. It couldn’t afford the usual approach. The Sternins had to find different solutions with the resources at hand. So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a "positive deviance” from the norm.

The villagers then visited those mothers at home to see exactly what they were doing. Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see.

In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were. I tell you this story because we are now that village. Our country is in trouble. We are in the midst of an economic meltdown like nothing we’ve seen in more than half a century. The unemployment rate has passed nine per cent. For young people ages twenty-five to thirty-four, the rate is approaching eleven per cent. Our auto industry has filed for bankruptcy. Our housing and finance industries are shadows of their former selves. Our state and local governments are laying off teachers and municipal workers.

It is worth reflecting on how extraordinarily lucky we who are doctors, or doctors-to-momentarily-be, are. Consider the contrast between what every other graduation ceremony taking place today must feel like—the graduation ceremonies for the undergraduates, the business-school students, the law-school students, the architects, the teachers—and what ours does. There are thousands graduating proudly today but fearing for their future. Many have no jobs, no sense of how they’ll make it. We doctors meanwhile remain with no significant unemployment. Virtually all of us can find ratifying and well-compensated work in our chosen fields, and that is emarkable. It is something to be deeply thankful for. Yet the idea that we can proceed oblivious to the economic conditions around us is folly. In fact, it is not just folly. It is dangerous.

Job losses and cutbacks have produced an unprecedented increase in the uninsured. Half of hospitals were already operating at a loss before the economy tanked, and the rise in patients who cannot pay their medical bills have since pushed many into insolvency. Hospital closures and layoffs have started, as you know all too well in Chicago. We will be affected by what is going on in our country.

More than that, though, we in medicine have partly contributed to these troubles. Our country’s health care is by far the most expensive in the world. It now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government at every level—squeezing out investments in education, our infrastructure, energy development, our future.

As President Obama recently said, "The greatest threat to America’s fiscal health is not Social Security, though that’s a significant challenge. It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”

Like the malnourished villagers, we are in trouble. . . . The vast majority of extra spending, however, is for the tests, procedures, specialist visits, and treatments we order for our patients. More than anything, the evidence shows, we simply do more expensive stuff for patients than any other country in the world. So the country is now coming to us who do this work in medicine. And they are asking us, how do they get these costs under control? What can they do to change things for the better?

It is tempting to shrug our shoulders. It is tempting to say, This is just the way good medicine is. But we’d be ignoring the evidence otherwise. For health care is not practiced the same way across the country. Annual Medicare spending varies . . .” Gawande then talks about the geographic variation in spending and the Dartmouth research which shows that "even within cities . . . a recent study of New York and Los Angeles hospitals found that Medicare’s costs for patients of identical life expectancy differ by as much as double, depending on which hospital and physicians they go to.”

He goes on to explain that in high-cost places, outcomes are no better, often they are worse , "whether measured in terms of survival, ability to function, or satisfaction with care. Nothing in medicine is without risks, it turns out. Complications can arise from hospital stays, drugs, procedures, and tests, and when they are of marginal value, the harm can outweigh the benefit. To make matters worse,” the Dartmouth research shows that "high-cost communities appear to do the low-cost, low-profit stuff—like providing preventive-care measures, hospice for the dying, and ready access to a primary-care doctor—less consistently for their patients. . . . We need to change the way we pay doctors, Gawande explains, paying for quality and paying "teams” rather than "narrowly specialized individuals. President Obama, I’m pleased to say, and is committed to making this possible in his reform plan to provide coverage for everyone. But how do we do it?

Well, let us think about this problem the way Jerry Sternin thought about that starving village in Vietnam. Let us look for the positive deviants. This is an approach we’re actually familiar with in medicine. In surgery, for instance, I know that I have more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful—the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.

Likewise, when it comes to medical costs and quality, we should look to our positive deviants. They are the low-cost, high-quality institutions like the Mayo Clinic; the Geisinger Health System in rural Pennsylvania; Intermountain Health Care in Salt Lake City. They are in low-cost, high-quality cities like Seattle, Washington; Durham, North Carolina; and Grand Junction, Colorado...

We know too little about these positive deviants. We need an entire nationwide project to understand how they do what they do—how they make it possible to withstand incentives to either overtreat or undertreat—and spread those lessons elsewhere.

I have visited some of these places and met some of these doctors. And one of their lessons is that, although the solutions to our health-cost problems are hard, there are solutions. They lie in producing creative ways to insure we serve our patients more than our revenues. And it seems that we in medicine are the ones who have to make this happen.

Here are some specifics I have observed. First, the positive deviants have found ways to resist the tendency built into every financial incentive in our system to see patients as a revenue stream. These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way business people do, on maximizing their high-margin work and minimizing their low-margin work.

Yet the positive deviants do not seem to ignore the money, either... Instead, the positive deviants join with their colleagues to install electronic health records, and look for ways to provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely... They think about how to create the local structures and incentives to make better, safer, more appropriate care possible. I recently heard from one such positive deviant. He is a physician here in Chicago. He’d invested in an imaging center with his colleagues. But they found they were losing money. They had a meeting about what to do just a few weeks ago. The answer, they realized, was to order more imaging for their patients—to push the indications where they could. When he realized what he was being drawn to do by the structure he was in, he pulled out. He lost money. He angered his partners. But it was the right thing to do.

I met another positive deviant, a thoracic surgeon named Dr. Mathew Ninan, who joined a group of pulmonologists, surgeons, and oncologists in Memphis to change the quality of care for lung-cancer patients in their city. "Our approach is simple,” he told me. "We will see every patient regardless of insurance status. We will make every attempt to see patients jointly in one visit. We will discuss every new patient that we see in a multi-disciplinary format on the same day and decide on a plan of treatment. We will follow every patient to track whether they receive the right treatment. And we will enroll as many patients as we can in clinical trials dedicated to improving lung-cancer care.”

To insure that unnecessary costs are avoided, they took yet further steps. The toughest was that the surgeons agreed to do no operations on lung-cancer patients unless the pulmonologist and oncologist agree that it is indicated. This is radical. "I have had to swallow my ego repeatedly to stick to this principle,” he said. Sometimes he’s had to persuade them an operation was best. More often, however, they persuade him to drop his plan and with it the revenue. But he did—because it was the right thing to do. No one talks to you about money in medical school, or how decisions are really made. That may be because we’ve not thought carefully about what we really believe about money and how decisions should be made. But as you look across the spectrum of health care in the United States—across the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. And as you become doctors today, I want you to know that you are our hope for how this battle will play out.

As you head into training and then further onward into practice, you will be allowed into people’s lives in a way that no one else in society is permitted. You will see amazing things. And you will develop extraordinary abilities.

Along the way, you will sometimes feel worn down and your cynicism taking over. But resist. Look for those in your community who are making health care better, safer, and less costly. Pay attention to them. Learn how they do it. And join with them.

If you serve the needs of your patients, if you work to ensure that both overtreatment and undertreatment are avoided, you will save your patients. You will also save our country. You are our hope. We thank you.

Posted on the New Yorker web site

Tags:  positive deviance  sternin  stopMRSA 

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