The Puzzle that is Don Berwick

(Hat Tip to Dr. John Dunn for this link)

I cried when I read Don Berwicks’s address to the 2010 graduating class at Yale Medical School.

I cried because he urges these new physicians to see the humanity of their patients. Not just to see it, but respond to it and stand up for it. He begins with the story of a woman who contacted him because she was barred from being with her husband outside of “regular visiting hours” while he was dying in a hospital ICU. Her husband complained, “She is not a visitor, she is my wife.”

Berwick writes ―

What is at stake here may seem a small thing in the face of the enormous health care world you have joined. It is as a nickel to the $2.6 trillion industry. But that small thing is what matters. I will tell you: it is all that matters. All that matters is the person. The person. The individual. The patient. The poet. The lover. The adventurer. The frightened soul. The wondering mind. The learned mind. The Husband. The Wife. The Son. The Daughter. In the moment.

I urge you to read the speech. It won’t take very long. It is pure poetry and excerpting poetry never works. There is a rhythm and beauty to it that is lost without the fullness and tempo of the whole thing. It will make you cry, too.

But I cried not only for the story Dr. Berwick tells, or the lessons he imparts. I cried, too, out of bewilderment and frustration over Don Berwick himself. I have written about this before.

Here is a lovely and loving man, someone who treasures the dignity of the people he cares for, who recognizes and honors their humanity and their sovereignty. How could this man be the same one who, as CMS Administrator, advocated locking physicians into an “evidence-based medicine” regimen that treats patients like mere statistics and confines personal knowledge of them to variables of age, race, and gender (like the Dartmouth Atlas does)? How could he push for the adoption of a program that assigns patients to an Accountable Care Organization without their knowledge or consent?

In my earlier commentary about Dr. Berwick, I noted that he was discouraging even face-to-face encounters between patient and doctor. He said standardization of treatment was more important than physician autonomy. He seems to embrace exactly the kind of regimented, bureaucratic rules that he decries in this speech.

Here is the essential conflict in American health care today. Is the patient a slab of meet to be efficiently cooked up in Atul Gawande’s kitchen? Or is the patient a fully-realized human being with a complete range of emotions, abilities, resources, and support systems? The latter qualities have enormous influence on outcomes and should be factored into any treatment plan.

But, more importantly, we have to always remember that the second word in health care is CARE. How can a doctor care for a patient if he doesn’t care about the patient?

At his best, Don Berwick understands this well. But he sometimes seems to have a Mr. Hyde lurking inside his Dr. Jekyll.

Comments (20)

Trackback URL | Comments RSS Feed

  1. Studebaker says:

    …the story of a woman who contacted him because she was barred from being with her husband outside of “regular visiting hours” while he was dying in a hospital ICU. Her husband complained, “She is not a visitor, she is my wife.”

    Same deal with my father. We could only see him in ICU for a small window to time a couple times a day.

  2. August says:

    “Even when it has no name and no locus, power can be, to borrow Mrs. Gruzenski’s word, “cruel.””

    This sentiment goes beyond just the healthcare system.

  3. seyyed says:

    wow i thought immediate family got unrestricted access to the ICU

  4. NotMyUsualHandle says:

    When my wife has been in the hospital I have been glad that they do not allow you to stay late. I could get rest without guilt.

  5. Dr. Steve says:

    This is entirely consistent for Dr. Berwick. The family should have access to their loved one. It is just that their “dying” loved one should not have access to the ICU!
    And who better than the good Dr. Berwick to determine who gets a ticket to the ICU?

    Be careful what you ask for, people, you might just get it.

  6. Uwe Reinhardt says:

    The irony here is that traditional Medicare offers patients free choice of doctor and hospital, and to both patient and provider relatively free choice of therapy — certainly relative to “managed care” in the private sector.

    And these features of traditional Medicare are exactly the ones routinely targeted by the critics of traditional Medicare — e.g., my friends at the AEI — when they claim Medicare is “out of control” because it is “fee for service” (their code for “free choice of provider” and “unmanaged care”).

    The ideal of managed care is precisely to base medical treatments on evidence-based best practices. Coverage decisions and formularies under managed care are based on the statistical analyses Greg slams here, as well as decisions on prior authorization.

    People often accuse me of being humorous when I talk about US health care. But I am German-born and Germans pride themselves on their lack of humor. The fact is that the US health debate on health policy is so funny that it comes across as such even when a humorless German describes it.

    So I thank you for this piece, Greg. You made my day.

  7. Don McCanne says:

    Physicians want to know the benefits and hazards of various diagnostic and therapeutic interventions, and use this information to help patients make informed decisions on their medical management. Although the private sector can be a source of important breakthroughs, the public sector does not require lucrative drivers to expand knowledge that can be beneficial for patients.

    Evidence-based medicine is based on, guess what… evidence. That’s a good thing. The public investment in obtaining this evidence provides a public good, and may provide evidence that is not readily available in the private sector when that additional information can result in lower revenues in health care.

    It appears that two of our most common malignancies – breast cancer and prostate cancer – are overdiagnosed and overtreated, with considerable harm to many patients, not to mention the very high costs entailed. We need much more information to improve our management of these malignancies, but that information is not going to be rapidly forthcoming from an industry that will lose revenues as a result.

    Using better information to help patients is for the benefit of patients – precisely Dr. Berwick’s lesson. If a government bureaucrat will give me invaluable information that private sector refuses to generate, then I want to listen to the bureaucrat – for the good of my patients.

    This also applies to health care costs, the better we can do in sorting out what is beneficial from what is detrimental, the better value we can obtain in our health care spending. If it takes public agencies to help us sort that out, then so be it.

  8. Al says:

    Uwe writes: “The irony here is that traditional Medicare offers patients free choice of doctor and hospital” … “People often accuse me of being humorous when I talk about US health care.”

    That is not really correct. Free choice in Medicare is somewhat of an illusion. Does a Medicare patient have the right to privately contract with a doctor that takes Medicare? No. Does a doctor on Medicare have the free choice to privately contract with a Medicare patient in order to provide what both the patient and doctor feel is appropriate? No.

    You are drawing your conclusions from an illusion, though humorously.

  9. Uwe Reinhardt says:

    Al:

    I find you argument a bit specious. Medicare patients do have free choice among providers that accept Medicare, which is most of them. I served on the precursor for Medpac for almost a decade, and we monitored that closely.

    Contracting privately with a physician who participates in Medicare is quite another story.

    If that were allowed, the fees Medicare pays would just become a floor — a government guaranteed pay — but physicians cold extract above that any amount from Medicare patients they chose. If that were allowed, you might as well not have Medicare at all.

  10. Brant Mittler says:

    Nice post, Greg. I stand by my comments about Berwick in a July 2012 comment to your earlier post.
    As for Professor Reinhardt’s comments here: managed care and managed Medicare (Advantage)purport to use “evidence” to guide or mandate treatment decisions to which their “providers” are contractually bound. Their “statistics” give an air of precision and “science” to what is still a political process guided by saving dollars rather than lives. Actual outcomes at specific practice sites for subgroups of patients outside of annointed selective clinical trial data ( ie the clinical trials the managed care managers think will save the most money) are largely unknown. So, what Berwick and the other managed care devotees have crammed down he throats of hapless patients is pseudoscience promoted by politicians and enabled by the NY Times through strategic quotes from its media darlings with the correct academic credentials. I suggest a thorough reading of Nassem Taleb’s new book, Antifragile.

  11. Frank Timmins says:

    Don McCanne says, “We need much more information to improve our management of these malignancies, but that information is not going to be rapidly forthcoming from an industry that will lose revenues as a result.”

    I find it hard to follow your logic Don. I don’t know of anyone who objects to the notion of gathering and utilizing information. The problem is how that information is used. When third parties (not the doctor or patient) are making determinations as to how this information is used we have big problems. Humans are not robots manufactured to exact specifications with standardized instructions on repair and maintenance.

    Human healthcare is both science and art, and bureaucrats are not artists.

  12. Greg Scandlen says:

    Uwe,

    I’m not sure what you are saying. I don’t know about AEI, but I have never, ever said FFS is the cause of the problems. In fact I have a very long history of saying quite the opposite.

    And as Frank said, evidence-based medicine is (and has always been) fine. There is nothing new about that. I believe that is why physicians go to medical school, read medical journals, and attend continuing education programs.

    The objection is not to evidence-based medicine, but cook-book medicine based on the whims of insurance company executives — call it accountant-based medicine.

    Meanwhile, I am in agreement with you — I have never found you especially amusing.

  13. Al says:

    Uwe: “I find you argument a bit specious. Medicare patients do have free choice among providers that accept Medicare, which is most of them.”

    It appears we have a different vision of what “free” is. Your type of freedom sounds more like a controlled freedom so I don’t know why you used the phrase “free choice” when it isn’t all that free. I can only ask why one would want to distort the meaning of the word “free” when there are so many more accurate words and phrases?

    “Contracting privately with a physician who participates in Medicare is quite another story.

    If that were allowed, the fees Medicare pays would just become a floor — a government guaranteed pay — but physicians cold extract above that any amount from Medicare patients they chose. If that were allowed, you might as well not have Medicare at all.”

    The problem with what you are presently saying is that Medicare existed in the freer form. It is true that the system didn’t work perfectly, but it did work at least where physicians are concerned. IMO it worked a lot better than what was created and could have been tweaked to provide much better results at lower cost than what Medicare evolved into.

  14. Thomas says:

    The speech itself was so powerful. He understands.

  15. Studebaker says:

    This post about the contradictions of Don Berwick alludes to the field of health ethics. I believe it’s safe to argue that everyone wants health care providers to be ethical. However, I often find that health ethicists are a little nutty in their views. One of the concepts health ethicists seem preoccupied with is health equity. Somehow it’s unethical to let someone rich live longer because they can afford to pay more out of pocket for their own care. But it’s not unethical to allow people both rich and poor to die prematurely merely because the poor cannot afford to pay for their own care and society cannot pay for all beneficial care that is theoretically possible.

  16. Don McCanne says:

    Studebaker writes that ethicists are a little nutty on health equity, stating, “Somehow it’s unethical to let someone rich live longer because they can afford to pay more out of pocket for their own care.”

    This implies that ethicists support a lower standard of care for all, a standard that wealthier individuals should have to accept, even though they would be capable of purchasing a higher standard.

    Quite the opposite, those with whom I associate contend that an equitable system should raise the standard of care for everyone up to an optimal level. Some have said that we can’t afford that, but the view of many of us, including Donald Berwick, is that we already have enough funds in the health care system to approach this standard, but we’ll have to do a much better job in reducing the profound medical and administrative waste in the system.

    A great start would be a properly designed single payer system (though Dr. Berwick dismisses it based on lack of political feasibility at this time). Unfortunately, the measures in the Affordable Care Act are far too ineffectual to make much of a gain towards this goal.

    That said, should a wealthy individual be allowed to spend $10 million on a medical program that might provide two additional days of poor quality life, care that an equitable system would not fund for the rest of us? The answer depends on whether or not it would remove medical resources from others who could really benefit from them. In general, since our resources are finite, rarely should they be used so foolishly.

  17. Al says:

    Don McCanne:

    I believe you are conflating the earlier ethics with the newer group ethic. The newer group ethic has frequently been used by organizations to promote the organization’s well being rather than the well being of the patient.

  18. dennis byron says:

    It amazes me that all these academics so easily and consistently mix-up health care and healthcare insurance. I have never seen what the AEI proposes but the basic choices for Medicare in terms of healthcare insurance are pretty simple:

    Choice 1: Retain Current traditional Medicare law:

    — healthcare provider prices fixed by law substantially below market prices,
    — cover a limited set of healthcare services in a relatively limited geographic area
    — growth in spending beginning in 2014/2016/2018 (not sure exactly) at no more than 1% about GDP growth
    — suffer a totally confusing secondary/tertiary/etc. market to make up for traditional Medicare’s shortcomings
    — gut an existing program (Part C) that increasingly appears to improve on all the problems described above

    Choice 2: Most discussed reform proposal:

    — keep insurance that works under the mismash of confusing traditional Medicare rules described above if you want (but at lower cost to both senior and government if next point is true and no more than cost growth estimates under existing law if not)
    — get something like Part C but hopefully less expensively (according to August JAMA research) to both the senior and the government because the competitive bidding will work more effeciently than current Part C competitive bidding (but see next point if competitive bidding fails to deliver as promised)
    — if competitive bidding does not work to hold down costs for senior and government, the growth in costs will be no different than current law but at least the senior will have many choices of healthcare insurance
    — begin this in 2022

    [As an aside, although it is true that seniors are moved into Medicare ACOs without their consent, at least with the demonstration projects in Massachusetts, they are informed and it doesn't matter anyways. That's because the ACO is in no way a limit; seniors can go to any doctor they want just the way they always could. The program is apparently testing the highly debated idea -- at great expense --that people should allow specialists to see their medical records. And the seniors in the ACO demo project can also easily opt out of that if they want.]

  19. Buster says:

    It amazes me that all these academics so easily and consistently mix-up health care and healthcare insurance…

    Academics aren’t the only ones to conflate health care and health insurance. Hospitals do the same when they assume the only way to pay for health care is with insurance; and they don’t have to compete for patients’ business, provide customer service or perform reasonable business practices.

    My girlfriend had health insurance and paid all the charges presented to her for medical care performed months ago. Recently, a hospital bill collector called and said that (call) was her “last chance” to pay before her account went to collections.” Since she had never seen an invoice, she asked him for a copy. “No, we cannot give you one. You’ll have to pay over the phone!” she was told.

    Oh well! I guess that bill collector didn’t make his quota that day. My girlfriend certainly wasn’t willing to pay an invoice she had never seen. Moreover, she’s not happy about discovering she was sent to a hospital for a simple X-ray and charged three times the rate a less-expensive facility would have charged.

  20. Jordan says:

    Very interesting, as always Greg.