My father would not have understood the phrase "24-7" when he practiced medicine, but he tried to live it. A general practitioner for 40 years in a small Connecticut town, he tended to farm injuries, heart attacks and poison ivy by making house calls and daily hospital rounds, working afternoons and evenings in his solo office, and answering a phone that always seemed to ring just as he sat down to dinner. He seemed to be on call not only 24 hours a day, seven days a week, but 365 days a year. So make that 24-7-365. I recall only two real family vacations in my entire childhood.
Romantic, isn't it? We've made such doctor devotion a nearly heroic memory. Marcus Welby never sleeps. Norman Rockwell paints the family doc sitting worried and pensive by the child's bed, waiting through the night for the fever to break. We easily understand why the compilers of the stunning 1992 photographic essay titled Medicine's Great Journey: 100 Years of Healing, chose for their cover a picture of a country doctor walking purposefully and alone along a gravel road, fedora on his head and black bag in hand, on his way to tend to us all.
Like many "good old days," these never were. Not, at least, as we would have wished them. Devotion is one thing; heroism, quite another. Medicine is a human endeavor with human limits. My father rarely vacationed, but he did sleep, forget, get angry and become sad. Although his patients appreciated his skill and reliability and he may have aspired to be there 24-7, it just wasn't humanly possibly.
Then I became a doctor, and it was the same for me. House calls were gone, but my day still seemed like that circus act in which a frenetic man tries to keep plates spinning by racing from pole to pole, arriving just in time to prevent each plate from falling. My time, the key resource, was stretched thinner and thinner. Sometimes plates fell. Quality of care suffered in my hands, as it did in my father's. We both cared deeply and tried hard to do well, but the spinning plates of need -- the flood of new scientific data in our journals and the evolution and complexity of the diseases we treated -- outstripped our struggle to succeed.
Changes in progress
For both my father and me, providing immediate, universal access and ensuring that our patients would always benefit from the best available scientific evidence were beyond hope and reason -- at least then.
But not now. Not, at least, by the year 2020. By then, if we keep our wits, I see four major changes that will make medical care more responsive and immediate than anything my father imagined in his half-century of practice. These changes stand a better chance of reducing the frenzy and producing safer and higher-quality care than my circus act ever could. Finally, the care my father and I wanted to give -- accessible, prompt, scientific and individualized -- will be within reach. The changes are:
* First, the work of medical care will shift from the provision of a personal service to the provision of information as its core process.
* Control over care decisions will shift dramatically from professionals to patients and their families.
* Care choices, made collegially by patients and clinicians, will rely on facts and knowledge more than ever.
* The flow of inpatient care will be smooth and continual, with less waiting and fewer delays. "Seamlessness," often aspired to but rarely achieved, will be the rule.
In fact, the latter three of these changes depend on the first. The transition of medicine from a "contact producing" to a "knowledge producing" enterprise is at the heart of medicine for 2020. It is a fundamental reframing of our work, though not of our goals and values. In my father's century, the system of care revolved around the central aim of causing the doctor and the patient to meet, whether in person, by phone or at the hospital. Care meant contact. The interactions that mattered most -- diagnosis, treatment and follow-up -- connoted the physical presence of the doctor. But that's changing.
Do I hear lamentation? Is Marcus Welby to be digitalized? Some interesting research suggests that computerization of a patient's medical history is far more productive than many personal interviews, and that even a computer psychotherapist can help many patients. But let's not take that too far.
Both the effectiveness of 2020 care and a good deal of the frustration that my father faced in practice are rooted in the idea -- unrealized in the 20th century and entirely plausible in the 21st century -- that the precious time and energy of the clinician should be preserved carefully for exactly those pastoral, manipulative and pattern-recognition tasks that only personal contact can accomplish well. Anything else that uses the clinician's time in the presence of a patient is a waste. Larry Weed, M.D., one of the most visionary critics of the 20th-century care system suggested that if we managed travel as we manage medical care, travel agents would try to memorize flight schedules.
When patients need information, they need information, not appointments. When they need medication, they need medication, not visits. America's childhood immunization rate soared when we began (with appropriate safeguards) to give shots in schools. To confuse "care" with encounters reduces the value of both care and encounters.
It is just the same within the care system, between doctors or between doctor and nurse. The currency of these interactions is not time together but rather the flow of knowledge. And yet the vehicles for knowledge flow in the 20th century are nearly the same as those of the 19th, and little more effective. I call for an oncology consultation with just one question in mind: Should we biopsy? And then I wait, as a horse-and-buggy-era paper form makes its way to the specialist's office, and as a receptionist makes a note that Dr. Jones will be in tomorrow morning. Dr. Jones then spends hours tracking down the X-rays before she finally tries (but fails) to reach me by phone with her opinion, settling for a scrawled note in the patient's chart that I might, if I'm lucky, be able to read. Two days pass to exchange a single, 30-second idea. The form does not fit the function.
Ideas, not encounters
We have produced the wrong thing. We needed an idea -- some knowledge -- but instead we produced an encounter. And with that mistaken direction come three more penalties: control decreases, knowledge decays, and delays arise.
Control decreases because of the system's complexity. Decisionmaking becomes opaque, especially to the patient. Responsibility becomes diffuse. Nameless multitudes march in and out of the room, and memory fades regarding who, exactly, said or did what. People pressed for time by the volume of demand have less time to introduce themselves, smile and, most important, listen carefully to the individual preferences of the patient.
It's time to simplify and use the benefits of parsimony to put the patient back at the controls. The information age, correctly brought to medicine, should allow patients to control their own bodies and destinies. Their lives are involved, and their choices should be too. In the locker room, jokes abound about the "Internet positive" patient, who finds needed information exactly when it is needed rather than making an unnecessary appointment to have an unnecessary conversation with a sometimes less-than-informed professional. The jokes will end by 2020.
This is where the facts come into play. A travel agent who tried to memorize flight schedules would often be wrong. So are doctors. Important medical journals number in the hundreds, and not all are in English. The gaps between what we know and what we do are predictably enormous, and the delays in incorporating important changes into care practices are predictably long. Paradoxically, the gaps grow as knowledge grows. Memory is the wrong process to rely on. So is reading. As the 20th century closes, we are exhorting doctors to use "evidence-based medicine" as their standard, but without a system for doing that, "read more" hardly works.
To frustrated healthcare managers and payers, the problem of widespread variation in physicians' practices seems like a problem of will or control over people. But it's a problem of design. The system in 2020 will use knowledge flow as its core process, and that knowledge will include the best-known fact base for decisions about diagnoses and treatments. At last, we will be able to make "best known" the standard, because, at last, we will be able to know the best.
One evening recently, my 12-year-old daughter and I wondered where Helen Keller was born. We found the answer in 30 seconds on the Internet. One morning in a surgical conference, someone asked if Neo-Synephrine decreases cerebral blood flow intraoperatively (a matter of some consequence if you are a stroke-prone 80-year-old about to have general anesthetic.) No one knew, and so the conversation moved on. Surgical conferences will soon look a lot different, as my daughter could have told conference attendees. The questions will reliably meet the answers.
We will find a way to make care transparent and make caregivers accountable for their results, while honoring privacy without compromise. On the 19th- and 20th-century hospital ward, medical records and their components lie strewn on desktops and in metal racks. Security is always an issue. That won't change in the electronic age. But we're smart enough to make it a priority.
The doctor is in
With its new focus on information transfer as its primary constraint, the 2020 system will not only shift control to patients and bring facts to care, it will vastly decrease waiting and delays. As long as we try to move people into one another's presence, delays are a serious threat. At a minimum, nights and weekends come, when we are "closed." During normal hours, the waiting rooms are full. Medical care spends much of its time "on hold." This is a function of the premise that care requires physical motion, such as getting "Person A" into the presence of "Person B."
Try finding Helen Keller's birthplace at 2 a.m. It's really easy. If we think of the job as bringing questions to answers -- not people to people -- the need for delay begins to disappear. Innovative doctors are already using e-mail with patients to become virtually available, even if nobody pays them for it yet. It is only a matter of time before we all do that and can make a living at it.
Strikingly often, the cause of delays even when people must meet people relates to information -- usually missing information. The operating room starts late because no one can find the permission form signed last night, or the preoperative cardiogram, or the surgeon.
Toyota began to revolutionize material production when its guiding genius, Taiichi Ohno, developed the kanban system of "just in time" manufacturing. Kanban seeks to ensure continuity in the flow of assembly down the line -- no delays and no inventories -- everything ready just when it should be ready, not before (inventory) and not after (waiting). Ohno broke through when he realized that if flow is to be continuous downstream, information must pass upstream continually. When the state of the system is thus made transparent to those who work in it, each can do his or her job exactly when and as needed.
The 2020 healthcare system will know that and act on it. It will deliver kanban healthcare. It will be able to predict demand and allocate resources through anticipation, not reaction. A smooth flow of care will be feasible because of the same focus on information capacity that puts patients in control and allows care to be based on knowledge. The best hospitals of the future won't need waiting rooms.
The 2020 healthcare system will affect the quality of care profoundly. Greater use of the evidence base for medical care will reduce the overuse of ineffective procedures and the underuse of effective ones. Reliable and timely communication systems will decrease errors, prevent misunderstandings, and avoid costly and hazardous delays in finding out what people need.
Putting patients in the driver's seat will increasingly ensure that the care system is listening more carefully and addressing patients' needs, rather than wasting time in unnecessary rituals, enforcing old rules and failing to take advantage of the inherent strengths of patients and their families. Rather than treating patients like infants and silencing them, the future system will act as it should -- as their servant.
Chiseled over the portal of the 2020 system, including its cyber-portals, will be the logo: 24-7-365. If we explained it to my father, he would smile. Fully confident that he could give his patients the benefit of his wisdom, his compassion and his technical skill, fully committed to the unchanged values of professional excellence, thoroughness and trust that guided his long career as a doctor, he now might even get a bit of rest.