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A letter to all pre-med students

Adam Newman | Monday, September 2, 2013

I love when I talk to someone who tells me they hope to go to medical school. Becoming a doctor is one of society’s most important professions and the need for them has never been greater. However, while it is great to see young people excited about medicine, it is embarrassing how little they know about the profession they are entering.
The health care field is changing very fast and there are many reasons why this is happening. The most important reason is cost. Our health care system is costly – we spend far more on health care as a percentage of our gross domestic product and per person than any other country in the world. The obvious response to this is, “Sure, we spend a lot, but we also have the highest quality health care system.” However, this really is not the case. On any quality indicator, whether it be infant mortality, length of life, five-year cancer survival rates and countless other quality indicators, America provides roughly the same and in many cases, worse quality than countries that spend less than us on health care.
To many, this does not make sense. “America has the smartest doctors, the most innovative drugs and the most advanced technology. Why can we not produce high quality health care?” The reason is these factors, while all good, are extremely fragmented and do not coalesce together in a way that provides smooth, cost-effective care. Atul Gawande, a renowned surgeon and health policy expert, has written, “[Imagine] building a car with Porsche brakes, a Ferrari engine, a BMW chassis and a Volvo body. Put it all together and what you have is an expensive pile of junk that doesn’t go anywhere because the pieces don’t work together.”
What health care needs is doctors to work less as individuals and more as a team across specialties. Currently, 40 percent of doctors work in a solo or two-person practice. Now, the number of solo and and small group practices is declining as many hospitals are acquiring small practices. However, even within hospitals and health care systems, the culture largely tends to be based on individuality rather than team care.
Why is it important to provide care in a team? Many doctors believe they work better alone, or that they do not want their compensation tied to the performance of others. The reason is that team-based care is important to take care of the sickest and most expensive patients in the system. Health care spending is skewed towards the sickest patients, as the one percent of most costly patients are responsible for 23 percent of the costs and the top five percent are responsible for 45 percent of all costs. The bottom 50 percent of spenders are responsible for three percent of all costs. The most expensive patients are those that have many chronic diseases (diabetes, cancer etc.) and need to see many doctors, undergo numerous treatments and take multiple drugs. When each doctor contributes a piece on the continuum of care without knowing what everyone else is doing, medical errors, adverse reactions, duplicative tests, readmissions, missed prevention opportunities and other bad outcomes occur. If doctors work together to create a course of care for a patient, many of these issues can be avoided and lead to a better quality of life for the patient at a lower cost.
There are many doctors (usually older doctors) who are very cynical about the state of American health care. Many doctors reflect upon the “good old days” and lambaste the current system that seems to be going to hell. This is, of course, their opinion. But what should be known is that these physicians advocate for a system that has grown much faster than the economy, has devastated the savings of families, lowered wages, put companies on the brink of insolvency and forced state governments and the federal government to cut back on essential priorities. Moreover, the older health care system too often placed the financial interests of the health care stakeholders over the health of patients.
The health care system is changing, which will surely upset some due to a natural opposition to change. However, we should be rejoicing that our health care system is becoming more focused on providing greater value – meaning higher quality care –  at a lower cost. Many systems are experimenting with having nurses manage the care of the sickest patients. New technology systems are making it easier to create and share records. Insurance companies are beginning to hold groups of physicians accountable for the cost and quality of the medicine they provide. All these things are happening  regardless of what physicians want. Even still, without having physicians, especially young physicians, who embrace this change, America can never hope to cure its broken health care system.