Care Redesign
Returning to the Meaning of Medicine: Three Pivots (11:18)

When Anna Roth, Health Director for Contra Costa County in California, first entered health care as a nurse, she was assigned to the old county hospital med-surg unit, which she describes as functioning like a small city. At the center of the unit were senior nurses Jan and Margo, manning the helm of the nurse’s station, managing surgical schedules, recovery room schedules, and assignments for everyone, including nurses and residents. “Each day, I would arrive, and I would get my 12 hours’ worth of work to be completed in the next 8 hours,” Roth says.

“One of the things I was struck with was the profound privilege it was to be in the presence of these people,” Roth says. “These people who came to work every day, completing the impossible within their 8 hours.” Each day would end with the house supervisor, Joseph, walking around with a clipboard, making sure no one had worked overtime and monitoring the bottom line.

Two weeks into her new job, Roth was assigned to Room 12 — the isolation unit, the AIDS room. “Most of the time, no one visited Room 12. Often, people in Room 12 spent days alone. This was the early 1990s; there was a lot of fear around AIDS. There was a lot of mythology. There was a lot of misunderstanding. There was stigma,” Roth recalls. She describes walking into the room and talking to a young man who was very ill. She brought in a doctor and Jan to help care for him, and they determined that he might not make it through the day.

Jan then spoke with Roth about a clandestine volunteer schedule created so that, as she told Roth, “No one on our unit dies alone.”

“I was invited to volunteer and work that night, secretly, to sit with my patient overnight,” Roth says. “It was during that night, in the darkness, in the silence, that I realized why I went into health care, and what it was all about. I realized the meaning of being part of something that was more than myself. I was invited into a group of people who were facing down fear, stigma, who were standing for social justice, and I got to be part of that.”

Roth went on to become CEO of the hospital and spent much of her job trying to figure out “how to get people to do things” during a time of great reform — electronic health records, payment and coverage reform, Medicaid reform, and new technologies and innovations she could never have dreamed of in the early ’90s. “It was a magnificent time, and I have to confess that I think I blew it on so many levels,” Roth says. One of her colleague’s senior leaders said to her, “Anna, one of the important things when you’re leading is to make sure to turn around. People are following you.”

“Think about these reforms: They changed the way we do everything, from the time in the ’90s to today, but at what cost?” asks Roth. “We’ve been talking a lot today about how the world inside the exam room, inside our units, even out in the community has changed in health care, but what’s been the cost for providers, and for those of us who work in care? Have these reforms actually brought us closer to the meaning?”

“The cost has been tremendous,” Roth says. She discusses a recent paper by Ashish Jha et al., “A Crisis in Health Care: A Call to Action on Physician Burnout.” In it, the authors talk about how today’s day-to-day demands of health care are at direct odds with the goals of healing and caring — colliding with what Roth experienced in Room 12 — and that physician burnout is such a profound problem they deem it a moral injury.

“As I talk today with you about incentives, I’m not talking either/or, but there’s an ‘and’ here,” says Roth. “We need to welcome and figure out how to leverage technology. We need to figure out how to welcome incentive reforms and bring in incentives, and we need to address the next big reform, which is the reform of our belief systems in pursuit of this moral recovery. We need to return people back to the purpose of medicine. Why did they go into it in the first place? That’s a big bite, but I think it’s within reach.”

Roth proposes three simple pivots:

  1. Listen carefully and ask the right questions. “We need to listen carefully to people and ask what matters to them, not what’s the matter with them,” she says. Also ask what happened to them. “By listening through that lens, it opens up a curiosity. How do you capture [patient] nuance in the electronic records? How does that nuance not get lost? We have to ask the right questions.”
  2. Challenge your beliefs. “Beliefs set boundaries. Beliefs are the basis of our boundaries.” Roth provides an example: When she was CEO during the H1N1 epidemic, the hospital strengthened its visitor policy. For infection control reasons, they did not allow children ages 12 and under to visit, which meant denying an 8-year-old from saying goodbye to his grandfather — who was also his primary provider — in the critical care unit. “We prioritized infection control over love, and it was something we didn’t have to do.”
  3. Trust people. “We need to trust people. We need to trust our workers,” says Roth. Continuing the story about the 8-year-old, she describes how upset staff were that his grandfather couldn’t see him. They came to her office to explain the situation and that it didn’t need to happen — they could’ve just put a mask on the boy, instead of following the policy that led to this tragedy.

Returning to the pivot about challenging one’s beliefs, Roth notes that she and her staff decided that people coming to the hospital to be with their loved ones were not visitors, and the hospital transformed its visitation policy to a welcoming policy.

“Ask yourself if your policies, your innovations, your changes, are telling people to do things that are not good for the patients, or that are at direct odds with the purpose that they came in for,” says Roth. “If you don’t believe it, go at night to your hospital if you have a visiting policy, and go walk through your units, because your staff are breaking the rules to do the right thing.”

Others are challenging their beliefs, too. Roth mentions Geisinger’s ProvenExperience initiative, for example, which offers a money-back guarantee if patients aren’t satisfied with their care. “[ProvenExperience] faces down this belief that we’re in charge, and that what patients are experiencing doesn’t matter, or matters less,” she says.

“What’s next for this, our pursuit in this moral recovery?” Roth asks. “To summarize, we need to listen with curiosity, with interest, and with open hearts. We need to challenge the belief systems that are really the basis of most of the boundaries within our system, and that are interfering with compassion and connection. We need to trust others. We need to invite people into the conversation. We need to invite them to return to the values that originally drew them into health care. Every decision we make should include the people that are affected by those decisions. What, in the end, do we need to do in addition to all the innovation, technology? We need to allow people to once again feel like they’re part of something more.”

From the NEJM Catalyst event Provider-Driven Data Analytics to Improve Outcomes, held at Cedars-Sinai Medical Center, January 31, 2019.

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