Escape Fire: Designs for the Future of Health Care
Cassie, Santiago and I recently visited the office of a pediatrician that we had been referred to. After we all shook hands and said hello, the doctor made the statement, completely unbidden, “healthcare is a mess these days.” Besides being a complete non-sequitur within the context of the visit, his comment sounded cavalier and resigned, as in “I’m the best you can hope for.” Initially, we tried to overlook the comment, along with much of the rest of his obviously well worn monologue for the next 20 minutes. There was almost no conversation, merely a recitation of his opinions in response to our questions, some relevant, some not. I came out of the meeting feeling that sense of dread I feel so often as I muse on our system of healthcare, particularly when I see it from the perspective of a patient.
I have the pleasure of working with a host of sophisticated healthcare practitioners, people whose smarts and values intersect in the care of the uninsured. These people are doing the good work and applying some of the best thinking available to the underserved. But I actually feel more vulnerable and less optimistic when I, with my commercial insurance and above average knowledge of healthcare find myself in the shoes of the consumer. In the past two years, I’ve had family members who received substandard care in name brand hospitals and were afraid of making a formal complaint for fear of retribution from the staff. Another family member was unable to get a flu shot at his doctor’s office. It seems that they forgot to order vaccine for children, even though the office is a Family Practice. The staff at the front desk suggested visiting a sliding fee clinic for the uninsured, essentially pitting an insured individual against uninsured ones for a dose of vaccine.
At a recent “drop in” appointment for a routine cholesterol check, what was promised as a 10 minute visit turned into an hour long affair for my wife. When the nurse finally came to the lobby and called for her, the staffer apologized for the delay; it seemed that she had misplaced my wife’s chart under some papers and forgot about it. Oh, and the insurance company declined to pay a portion of the bill for this simple preventative test that could potentially save thousands of dollars of expensive healthcare by catching the markers of a serious illness while a person is still young and healthy. On top of the $20 co-pay, we were stuck with another $20 that the insurer refused to pay.
Any thoughtful review of the healthcare system in the US suggests these types of anecdotes are more than one person’s grousing. The litany of failures grows: the only country in the developed world that does not guarantee healthcare to everyone, with nearly 40 million citizens uninsured and for those with insurance, at least half of all claims paid are for medical treatment necessitated by lifestyle choices like obesity, smoking and other high risk behavior. Medicine and healthcare is disproportionately applied at the wrong stage of life. Our country spends $1.9 $2.1 trillion a year on care while the health of the population gets worse by most standard measures and 100,000 people die in hospitals each year from preventable medical errors.
If you’re not worried yet, there is plenty more bad news. The bottom line is that this is a slow motion train wreck and there’s a lifetime’s worth of work to do. The good news: The Institute for Healthcare Improvement (IHI) has been pointing out the elephant in the room for over 15 years. Its co-founder and spiritual leader is Donald Berwick, MD. He’s a leading authority on healthcare policy and improvement, a professor of pediatrics at Harvard and all around gut check on the industry. Escape Fire is a collection of 11 of his keynote speeches at the annual Forums on Quality Improvement offered by IHI. He is a physician who understands the art and science of medicine, but never lets it lose its focus on who really matters in the system: the patient. His speeches are like his approach to medicine: equal parts scientist, efficiency expert, storyteller and unwavering humanist. His examples are drawn from some of the more heroic and tragic stories of modern medicine, including stories from his own struggles as loved ones entered the healthcare system and their safety was continually in peril. But he also brings parallels from NASA, corn farmers in Iowa and Harry Potter. Berwick tells us where we’re going and what’s possible and not only to not give up home, but to work effectively and with compassion.
Ed's Book List 