by Fred Pelzman, MD, Contributing Writer, MedPage Today August 28, 2023
Fred Pelzman of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what's going on in the world of primary care medicine from the perspective of his own practice.
There's got to be a better way to move ideas forward.
Through the years, we've all had good ideas -- things that we think will help our practice, things that will help our patients, ways to improve the electronic health record, a better way to communicate results to patients, ways to overcome healthcare inequities. Ideas large and small.
Sometimes we've been doing something a certain way, the same way, over and over again, and finally realized, "There's got to be a better way." Sometimes we see something for the first time and our common-sense alarm goes off. "This can't be right; there's got to be a better way." And sometimes we wake up in the middle of the night with an "aha" or "eureka" moment.
How many of us have woken up to something we've written on scrap of paper on the bedside table, a brilliant inspiration that woke us in the middle of the night and seemed just perfect, but in the morning we suddenly can't make sense of it -- some indecipherable scrawl scribbled in handwriting that we don't even recognize as our own? I bet each and every one of you reading this has one, two, or a hundred, of these floating around in your head, on Post-it notes stuck on your desk, or in multiple notebooks or countless to-do lists on your computer.
But how do we convince those with deeply vested and entrenched interests in what we do, who often have such a strong interest in keeping the status quo the status quo, that switching to a different way might just make a lot of sense for everybody?
Trying to get large-scale bureaucracies, insurance companies, federal regulators, and the general public to change behaviors, rules, and silly protocols can seem like trying to move a mountain. Having to go up the chain of command, convince multiple governance committees, present a detailed business plan, demonstrate a return-on-investment, or conduct a randomized controlled trial probably isn't always the best way to bring about effective change.
But trying to move too fast on your own can be equally frustrating. Just deciding "I'm going to switch and do it this way," without the support of the institution behind you, can often lead to more trouble than it's worth.
Sometimes it takes a sentinel event, a dangerous outcome, a poor online review, or a citation or probation from an auditing organization to get something as big as an academic medical center or hospital to overcome the inertia of what it's always been doing.
Take, for instance, the recent institution of new sepsis guidelines that have been recommended for hospitals, which include the creation of rapid response teams using data from multiple sources to detect impending sepsis and step in to prevent bad outcomes for patients. Hospitals have had sepsis protocols for years, but often these things are not instituted in ways that really make a difference. Too many patients are still dying from sepsis even though it feels like we have the tools to keep this from happening so often.
The same has been true for measures to prevent antibiotic overuse, urinary tract infections, and falls in the hospital. Just because someone has created a pathway or set of protocols that seem like they make sense doesn't necessarily mean that they are going to work. And just because I had a really good idea one night while I was sleeping doesn't mean that that's going to be the thing that helps our patients get their vaccines, take their medicines, achieve mental health, or update their healthcare maintenance.
There have been through the years so many different iterations of practice improvement pathways, from PDSA (Plan-Do-Study-Act) cycles and Six Sigma, to large committees studying serious problems, to local quality improvement efforts led by individuals and small teams. But even with all of these efforts, all of this time and energy, it sometimes feels like we're not moving the needle on the dial as far or as fast as we should. Do we need radical and revolutionary change, or do we need slow and steady change that wins the race? Or do we need both?
Maybe there is no one right answer. Perhaps each problem needs a different approach -- sometimes a focus group, sometimes a groundswell of social media, sometimes an N-of-1 experiment, and sometimes a large multicenter randomized controlled trial. Maybe in some cases we need an exposé of glaring inadequacies and a little bit of shame to make people change.
I would love to hear from all of you reading this what you think would work for what bugs you the most. I know that a lot of you are going to say in the comments that things are never going to change, that we been complaining for too long, and that the insurance companies, the pharmaceutical industry, Congress, and the general public are never going to change.
But if we're ever going to achieve an equitable and just healthcare system that takes care of everybody, that gives us all the care we would demand for ourselves and for our families, then perhaps it's time we get up off our butts and start moving things forward -- the little things and the big things, all of it.
And let's never accept being in a state of inertia.