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I’m a big fan of behavioral economics for those of you that have listened to me for a while or know me. One of the podcasts I like listening to occasionally is Freakonomics. They had a podcast recently. I don’t know how recent actually because I look at the Archives. I ignore it. But podcast 202 was, “How Many Doctors Does it Take to Start a Revolution?” I take that back. I think that podcast might have been five years ago. Okay, somewhere between time flies and whatever.
The model of medicine
In that podcast, a physician named Jeffrey Brenner out of New Jersey talked about the model of medicine in the United States, particularly the educational system for physicians, and referenced that it was founded off of the Greek model of medicine. He summarized it as two years of memorization, followed by two years of rounds in a hierarchy where you can’t question senior physicians or embarrass them. That’s not particularly flattering of the educational system for our physicians in the United States.
He likened it to being inducted into the priesthood. What he meant by that was that essentially you join a club of wealth, power, and influence. Dr. Brenner laments that our US healthcare educational system does not train physicians to be critical thinkers.
To be clear, I’m not insulting anybody. I’m not saying we don’t have any critical thinkers that are physicians. I am saying that just because 1) he said that and 2) even if you believe that, it doesn’t mean that a physician can’t be a critical thinker. As he’s stating it, it just means that the system isn’t designed to create them. It isn’t teaching that. He asserts that it’s discouraging critical thinking.
Why is this important? And why are we talking about it here in a data and analytics podcast? Well, our entire US healthcare system is based around physicians. Nurses are phenomenal. I have enormous respect for them, but they’re generally forced to be subservient to physicians and do not question them. So most of our systems, hospitals revolve around physicians. Outpatient care revolves around physicians.
We have to think about, “How is the system structured? What are we creating? And what are the side effects of this system?” If you wanted to make better cars, you would probably look at data on the breakdowns of vehicles, manufacturing defects, malfunctions, and more. You would look at how the vehicles perform after making them, call it the results hint-hint nudge-nudge. To improve the results, meaning fewer defects, fewer breakdowns, cars last longer, and so on, you would then enhance the design and the manufacturing due to these data that you analyzed after having manufactured your product. You might consider doing something similar if you wanted to improve your hospital’s clinical outcomes, your clinic, or your practice, whatever the case might be, whether it’s physicians or nonphysician practitioners.
Who’s qualified to review clinical outcomes? For the most part, it’s docs. But let’s think about a perverse incentive here. Why would you want to look at data on clinical outcomes if you’re a physician? I’m not talking about researchers who look at other physicians’ data in terms of performance, metadata, and all these kinds of things. I’m talking about a physician looking at their performance, their clinical outcomes, and looking at that data.
If you want to improve outcomes, that requires identifying where one could improve, which means potentially identifying mistakes, errors, or even, dare I say, deaths resulting from care from individual physicians. That requires admitting that there were errors, that a doctor made a mistake, or potentially could have done something differently that might have resulted in a better clinical outcome or even a lack of death.
The problem with our system is that it means liability. Ah, malpractice claims, big dollars, huge issues. So there’s a massive disincentive in our system that prevents physicians and clinicians in general from being able to look at their own mistakes or how they might improve their performance in clinical outcomes. Unfortunately, there’s one other thing that also plays in, which is reconciling an ego with identity issues of perfection or, for some physicians, sort of a godlike complex.
Again, I’m not trying to knock anybody. Please don’t take this personally. I’m talking about a system and its effects, not an individual. I have friends that are physicians, some very close, and I adore them. And I have much respect for them as people, not just as clinicians.
For the most part, clinicians looking at their clinical performance isn’t done. I mean, have you ever heard of a hospital publishing its death rate or its error rate, or a physician publishing their data, or even how many physicians look at their data? I mean, I don’t think it happens. So they’re not allowed to review their data, publish their own clinical results data, and be discouraged from doing so. Part of that is a liability. Part of that is culture.
Let me go back to the statement by Dr. Brenner talking about training in med school and not to question the hierarchy, not to ask the senior physicians. So if that’s what people are taught, why would they look at the data? We have all kinds of different factors pushing away from reviewing their data.
We’re focused primarily on financial data, not clinical data. So this isn’t our purview directly. This is relevant because our system revolves around physicians. There is a culture in part based on the training for physicians and based on liability and other things, even PR… Imagine a hospital PR nightmare. The deaths in the hospital would be a PR nightmare for your hospital. And so there are business incentives also to keep that from happening. So it isn’t just physicians. It’s the entire system that is geared that way.
All about the culture
Suppose there’s a culture away from a review of data in our healthcare system, that carries over to the business practices. If a front desk isn’t doing their job, that means there’s somebody probably to blame. But who’s going to look at that data? Do we have a culture of looking at data and identifying error rates and how we can improve it? We don’t believe in the US healthcare system. And in a small practice, the physician might even feel responsible for hiring that person. Or the practice manager who hired that person might not want to take accountability and recognize that they might have made a mistake either in hiring that person or keeping them on board.
Check the data
There is a disincentive from a psychological and an ego standpoint for us to look at data to identify our performance and see where we could improve. We all suffer from this. This is the human condition.
Slowly, we’re seeing some of this change. We see some change towards a data-driven system, towards data-driven decisions, and some culture around financial and even just looking at and reviewing data. Part of that, I think, is also the fact that healthcare is being driven so much towards a business and away from care. That increasingly pushes towards looking at data and results. And also have significant capital coming in.
You have private equity and publicly traded entities and things like that own hospitals and systems and physician practices. And all the private equity guys, I know, love data. They all got their MBA with me, and they’re quants for the most part.
All those things, I think, are leading towards some change in the system. But I did want to mention that we have these systemic things that push us away from that. And we have to identify those and recognize those so that we can overcome them.