Opportunity is missed by most people because it is dressed in overalls and looks like work.—Thomas A. Edison, U.S. inventor (1847-1931)

Many revolutions in medicine have come through scientific breakthroughs: penicillin, drug coated cardiac stents, pulse oximetry. We are witnessing a great medical breakthrough based not on science but on work transformation. The traditional approach has required one physician to provide answers to one patient at a time. As knowledge of medicine has increased, this has gradually been supplanted by multiple agencies caring for one patient. This partially coordinated system is not meeting the needs of the public, the patients, or the providers. We have begun the revolution to a new approach to patient care. Not unlike the transformation of car manufacturing in the last century, healthcare participants are re-examining the assumptions about the way we deliver care to patients in various settings.

Hospital medicine is leading the way in this new approach to patient care. This approach is shifting the focus from the single patient to the patient population. It is much easier to see a patient and decide their individual care than to work to change a system of care. Changing the system of care will demand many things of us, including:

We have begun the revolution to a new approach in patient care. Not unlike the transformation of car manufacturing in the last century, healthcare participants are re-examining the assumptions about the way we deliver care to patients in various settings.

We will learn new ways of doing things. We did not learn systems approaches in medical school or residency. We were going about the business of absorbing and applying medical and technical knowledge to heal those around us. Measuring the quality of what we did, collating results, applying new programs, and re-measuring were not part of our daily learning.
Understanding that poor outcomes are the result of broken systems and not individual mistakes is only the beginning. As systems approaches are applied to throughput issues, pre-operative care, and ICU care, we will transform the care of numerous patients—not just the patient under our individual care. In order to do this, we will embrace new sciences. It is no longer sufficient to place blame on something that did not work correctly. We must engage in the process of identifying root causes and participate in revisions to prevent future errors.

We will learn to be team players. As doctors our definition of team often means that the doctor is the captain and everyone else takes orders. But in today’s medical complex this is not the definition of a team. The many individuals who deliver care in an often uncoordinated way have expertise that exceeds ours in various aspects of patient care. Collaborating and delegating to each individual’s expertise leads to improved outcomes. Participating while others lead and respecting their contributions is necessary to achieve transformation of hospital care.

We will develop partnerships with our institutions. The traditional approach of the medical staff as an adversary to the administration no longer holds. That approach will yield to an approach of common goal setting, problem solving, and shared gain. For this we will learn new languages and a new respect for trying to move a complex organization in a new direction.

We will work under greater scrutiny than physicians before us. The discussion about quality in the past has been—in many ways—lip service. A number of organizations continue to note that we are not creating excellence in healthcare with our current approaches. As the public and private agencies that pay for healthcare increasingly question what they are buying, measurement of and payment for actual results will escalate. We may see the day where institutions and practitioners are paid directly on results achieved and not on the patient encounter that is defined simply as a patient-healthcare interaction.

We will embrace technology. Given the vast information that needs to be marshaled for use in patient care, the tools of technology will allow us to focus on the bigger picture while we are reminded of small items that need compliance. Exhorting someone to remember all care benchmark items and interventions creates minimal improvement. Harnessing technology to automatically do what is required (or to prompt someone on the care team to do it) allows us to focus on what no one else can do—provide solace, guidance, and advocacy.

We will learn to be specialists. There is some debate as we evolve on what we should be doing for patients. Who should care for the orthopedic patient? What about the appendicitis patient with no other medical problems? We still think in terms of what is beneath us professionally and what is unnecessary. This is not the thinking of a specialist.
A specialist assumes if they are asked for an opinion that the physician asking recognizes their own knowledge gap and needs assistance. As we become experts in medical care in the hospital, our knowledge will continue to exceed others. Our ability to understand the vagaries of health plan limits, patient care needs, facility and home care availabilities gives us an opportunity to use our expertise to advocate for patients. The recommendations and problem solving that we bring to the bedside are independent of the patient’s diagnosis, age, or gender. If all we give is solace or information, is that not a great enough contribution to the care of a patient?

We will retrain those in our institutions who have been doing things the same way for many years. Nursing will understand that availability means better job satisfaction for them and more timely care for their patients. We will train others in medical advances and set the protocols and benchmarks in a more timely way. We can leverage the knowledge we have for the great volume of care we deliver, thus bringing to many patients the latest recommendations. In conjunction with our hospital colleagues, pharmacy, nursing, and others, we can create change at a faster pace than has traditionally been possible.

We will teach those in training programs that this new approach to healthcare includes much more than our ability to pick the correct antibiotic. Our responsibilities are broader than ever before and now include transition management, resource allocation, advocacy for vulnerable and elderly populations, and prevention of hospital and system errors.

We will define ourselves for others. We will establish our specialty through advocacy, training, and board certification. We will define our role in partnering with our institutions, colleagues, and the healthcare system. We will lead by example to our colleagues and organizations.

And finally, we will work. We are in a position to transform the system in which we care for patients. This unprecedented opportunity of a lifetime will take dialogue, compromise, and sweat. It will not be an easy task. But as we harness our members’ energy, intelligence, and ideas we will lead the way to a revolutionized healthcare system. Let’s not miss this opportunity. TH

Dr. Gorman is the president of SHM.

Hospital Medicine Breaks Through