In this second installment of Dr. Polifka’s Africa journal, he describes his participation in medical education for the medical students and interns in the rudimentary training program at the John F Kennedy Medical Center in Liberia. For the entire country with a population of 3.4 million, there are only 52 physicians. Michael describes his personal transformation to a view that “all health care is local.” That’s how he feels change will happen and it’s how he’s decided to spend his time. See what you think.
Mark
Dr. Michael Polifka’s medical journal from Monrovia Liberia- March 2008
The medical ward had about seventy beds divided up into six bed wards. It was but 75% filled, not for lack of patients in the country but rather because of lack of any public funding or health insurance. With the profound lack of virtually all standard daily medical supplies the hospital had to resort to having most patients pay an upfront deposit for medicine before they could be admitted and then pay for every lab or x-ray test prior to it being done.
Some of the patients lived in or near the capital but many of the patients had been to other medical facilities in the country recently and had come to ‘the JFK’ for more advanced treatment; all were very sick. In one ward were mostly patients in their 40s and 50s, too young for the significant stroke, kidney disease or heart failure they had resulting from severe uncontrolled hypertension. The next was a room with older patients often with cancer presenting too late for effective treatment even if there were oncologists or surgeons available; there weren’t. The one starkly furnished room where there was up to date treatment available (from international sources) was the female AIDS ward; it was always full.The afternoon outpatient clinics were more of the same illnesses, severe hypertension, heart disease, pneumonia, and diabetes along with the more common intestinal parasites, typhoid fever and malaria (lots and lots of malaria). There are remarkably few patients with just aches and pains. My days are always full and satisfying, feeling that I have added a bit to the care of the patients being that day and to seen in the future.
Yesterday was eye opening to say the least. A 16 year old girl who had slipped into a coma the previous night was presented to me on morning hospital rounds. She had been slowly deteriorating for the past five days (she had walked into the hospital) and the cause unrecognized by all the nurses, med students, and interns that had seen her over that time. As I was about to begin a Socratic questioning of the medical students about the causes of coma, I noticed the IV fluid the patient was obtaining was dextrose water, apparently only that since admission and was certainly the cause of her condition.
My comments were direct but restrained, aimed at education during the last minute change in treatment that of course did nothing to change the expected outcome. She died in front of us. Through the day I found myself perseverating about the case, trying to grasp the magnitude of the problem. Where do you start? The immediate lesson to be taught about the IV fluid management was easy to present, but what about the bigger picture? Certainly being accusatory is useless at best; for the med students have all taken nine years to get to the 4th year of med school, with little in the way of textbooks, school closed every couple of months for undetermined amounts of time and no real clinical training. The interns all in their 40s have taken even more time to get to where they are, trying to learn without even the most basic clinical equipment to support them, and with few attending physicians to supervise and teach them. And there are but 52 physicians in the entire country, many of whom are elderly, hanging on hoping there will be someone soon to replace them.
Worldwide it is increasingly being recognized that real improvement in the developing world comes not from large grandiose plans (more often than not from those outside) but from those working locally. The task of returning this medical center to its prestigious level of two decades ago is a very large barrel to fill. Dr. Dennis and his small attending staff certainly have made major contributions in the past two years adding to the barrel, but there is still is so much to do. What we accomplished here is but a ladle-full added to that barrel, but I am impressed by the belief of my new friends here that this is a pail that can be filled. I have been privileged to add a few drops to it.
Michael
The performance of health care systems interests me greatly, as it is my job to help my local health care system be the best. Recent evidence suggests we are not getting better. In fact, one study suggests the disparity in health outcomes is getting worse. That is, some people benefit more than others from our health care system in the US. The income inequalities translate directly into health outcome inequalities. And racial differences also are getting worse. How can we tolerate a society where we apply our resources so unfairly?
The researchers in this study looked at health outcomes by county in the USA and then looked at race, gender, and socioeconomic class. The results are very disturbing. “If you look at the extremes in 2000, men in the most deprived counties had 10 years’ shorter life expectancy than women in the most affluent counties (71.5 years versus 81.3 years).” The difference between poor black men and affluent white women was more than 14 years (66.9 years vs. 81.1 years).
Of course people with lower incomes have less access to health insurance. I don’t think this is fair or reasonable, but even more disturbing is that among people with health insurance, there are still racial disparities. I cannot help facing the terrible likelihood in all this — that racism persists in health care workers.
There is some hope here. Between 1966 and 1980, disparities in health outcomes actually got better in the US. It’s since 1980 that the gap is widening. What really worries me now is that the economy is in tough shape and government will have trouble finding the resources to do the right thing. What homeowner and voter will support more taxes this year? What politician would suggest it?
But health care needs to be like education- we should all have access to a basic set of benefits. So where do we get the funding? I have a simple idea — we are now spending $5,000 a second in Iraq. We can’t afford to further mortgage our kid’s future, so we better figure out a way to pay as we go. According to forensic psychiatrist Marc Sageman's book Leaderless Jihad: Terror Networks in the Twenty-First Century, our current policy is likely creating more terrorists anyway. We could fund a lot of health care for the uninsured with $5,000 a second.
This week I had an interesting conversation with my son. A college senior, he’s considering job options in his field of environmental science. Possibilities include various types of nonprofits, research, and environmental education organizations. 
As we talked about his ideas, and he does job interviews and gets offers, he is asking about health insurance.
Notably most organizations tell him that’s up to him. So here is the son of a physician executive, successfully launching into the workplace, with the strong prospect of not having health insurance.
As you know, I believe that we need to take a hard look at how health care is managed and funded in this country. The current system is way too complex, saddled with very high administrative costs, delivers care in uneven and illogical patterns, and leaves some 47 million Americans not covered. Here are three key problems I see:
- Government promises more benefits than it is willing to pay for, and passes the uncovered costs to private health insurance
- The health care payment structure is set up to reward visits to multiple doctors and lots of tests rather than coordinated and planned care, especially for chronic illness.
- Access to care is different depending on where you live and what kind of insurance you have, if you have any.
A recent New York Times has a great essay illustrating the problems of multiple tests and doctors http://www.nytimes.com/2008/03/11/health/views/11essa.html?ref=health
And if you're following politics and would like to read some outside analysis of each presidential candidate's health care reform policies, check out the Commonwealth Fund, a private non-profit that works on health care policy analysis. http://www.commonwealthfund.org/
You can also access information on this site about the health of populations in the United states, by individual state http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=494551
The information on Vermont is very up to date, identifies Vermont as the third healthiest state in the country. It also confirms the clear evidence that the most cost effective health systems in the world and in the US are primary care based with high levels of generalists and low numbers of specialists. By US standards Vermont is high in generalists, low in cost, and has excellent outcomes. By international standards we have a long way to go.
I’ve been engaged in some healthy conversation with members of our Quality/Safety Department recently about how organizational change occurs at the level of the individual worker. Health care organizations have recently been looking outside ourselves to other industries for performance improvement ideas. The “Toyota model” of performance improvement is based on the teachings of Deming since the 1940s and has transformed auto manufacturing. The same principles have been used in a number of healthcare organizations in the United States to dramatically improve processes, standardizing, becoming more reliable, and reducing waste. Examples include Virginia Mason Medical Center in Seattle, and Bellin Healthcare in Green Bay Wisconsin. Our own efforts in Lean Six Sigma training and process improvement here at SVHC have improved the outcomes for care at end-of-life, with cost savings; reduced “bedsores” at Centers for Living and Rehab, and a number of other hospital processes.
When this team shows up to work on me, I want them to have a flawless execution of their process, and enjoy their work. |
So the debate is: must we change the culture (attitudes, willingness to change, engagement in process improvement, trust, team behavior) before people can participate in performance improvement and change in their work? Or whether the experience of improved work leads to the changing culture. Our health system is currently engaged in accountability training, one component of which teaches that in order to change culture, peoples beliefs need to change. And beliefs are based on experiences. so if you really wants someone to change their beliefs, they must experience something new that tells them that their previous beliefs about the organization are no longer true.
Brent James, MD, teaches that an organizational culture of safety includes an organizational commitment to detecting and analyzing patient injuries and near misses, and is a "just" culture. A "just" culture has also been described as a learning culture. He distinguishes this from cultures that are "pathologic" (shoot the messenger), and those that are" bureaucratic"(write a new rule). A learning culture understands the broader implications of patient injuries or near misses and generalizes. To generalize requires standardizing a process and improving it.
So the dialogue I have been having (and I will upload a couple comments from my colleagues) surrounds where to focus the energy. Can one "teach" a new culture? Or does one experience a new culture because processes and behaviors have changed? I think one has to "teach" that there are behaviors that are more effective (like asking for feedback and really listening), but that in the end it is the experience of the improved process in the workplace and improved behaviors in the workplace that changes the culture. Our health system is on that journey, and has experienced dramatic improvements in infection rates, complicaiton rates, and mortality. Now we need to unleash the energy of every person who works here to be able to help the organization standardize and improve their own work process, just as Toyota has done with cars.
Read No Satisfaction, the complete article on the Toyota method that appeared in Fast Company Magazine.