The History of Medicine in the U.S. Provides Lessons for Our Future

The practice of medicine has evolved dramatically since the 19^th century when it was really a cottage industry and a physician was like a tradesman. Back in those days, there wasn’t much a doctor could do to cure patients. Medicine lacked a scientific basis and even where the science was understood, there were no medicines that worked.  The doctor’s role was often to provide a sense of hope and comfort to the sick or dying.

It’s quite fascinating to look back at the history of medicine where the original hospitals were alms houses for the poor, created by philanthropic organizations to care for the sick and dying who had no place to live and no family to take care of them. Up until the early 20^th century, people pretty much received medical care at home and died at home.

Interestingly, from the very beginning of modern day medicine, Americans never had a debate about whether healthcare is a right. We’re now experiencing the ramifications of our indecisions as we delve deeper into healthcare reform and ponder how we can provide a better, healthier future for all people. If you look back to 1964, President Lyndon Johnson introduced Medicare legislation to provide health coverage for seniors. Medicaid legislation was also passed, but was not set up to care or provide healthcare coverage for all of the poor in this country. Originally, through the Aid to Families with Dependent Children (AFDC) program, Medicaid covered mothers and their children. Later, Medicaid covered the indigent elderly, so that there would be coverage for older people who needed nursing home care but couldn’t afford it. It is a little appreciated fact that most States pay much more of their Medicaid budget for nursing home care than they do for hospital and physician care. (Today, for a fee, Americans can learn how to get Mom and Dad’s money so that they qualify as poor and the government (Medicaid) will pay for their nursing home care).

It wasn’t really until the 1990’s and 2000’s that individual states started creating special Medicaid programs for poor adults to cover doctor bills and acute hospital care, in large part because of the AIDS epidemic. In 2010, the Affordable Care Act saw the expansion of Medicaid as one of the ways to provide health insurance to a larger segment of the lower income uninsured American population.  Unfortunately, with the ever increasing cost of medical care and the downturn in the economy, the move to cover more poor people is a major factor in the near bankruptcy of a number of states.   

 Leaving aside for a moment the question of how we pay for care, it’s amazing how far medicine has come. Thanks to the tremendous technological advances of the 20^th century and a better understanding of the science behind medicine, physicians now have tools that actually cure patients and they have training that is rooted in science. The combination of clinicians (doctors, nurses, and others) that are scientists and medicines and tools that work, has led us to the thing that we know as the modern day hospital and modern day medical care.  

Over the past 60 years or so, as the practice of medicine has become more sophisticated and complex, we’ve seen physicians organizing into groups. In this new climate, it’s become increasingly challenging for a physician in solo practice to function on his or her own, partly because these practitioners don’t have enough hours in the day to attend to all of their patients’ needs, nor the resources to implement the new systems to deliver state-of-art care.  Solo practitioners work extremely hard and have dedicated so much of their lives to the practice of medicine. These physicians have been faced with difficult decisions and many have merged into group practices which offer a number of benefits - giving patients expanded access to medical care and giving physicians a more efficient way to deliver care (without sacrificing their personal lives). And today, as we continue to navigate the uncertain waters of healthcare reform, GBMC is working to strengthen its employed network of primary care physicians, while also offering support to independent community physicians.

Medicine as it used to be is ending. We are moving toward a new era of better health and better care at lower cost. At GBMC we want to be a part of the national solution. We are building on the beauty and power of the commitment of hard working, well trained doctors and other clinicians as we create new models to make it easier for them to get the job done. I’m proud to say that the GBMC Healthcare system is very good and will get even better! 

YOU Can Redesign Our Systems and Create Positive Change

I've talked about empowering our employees to make positive changes and why it's so important not to "check your brain at the door," but I thought it was especially appropriate to revisit this topic after a rather interesting employee lunch session I had this week. On a regular basis I hold these employee sessions where about seven or eight staff members are invited to an open discussion. These sessions are a great way for me to narrow the gap between the front office and the front lines. It's important for me to know what the people actually doing the work believe, and it's important for them to hear what I believe as well.

This past Tuesday was a particularly good session where one of our employees raised the issue of hospital acquired infections and our ability to protect the patients. The employee demonstrated how there is always room for improvement in any department, explaining that when patients come to radiology for a study, for example, they often come in on a stretcher with their belongings (often jewelry) laying on top of them. So, when it's time for the study, the technicians must remove the belongings off of the stretcher and place them on some surface in the radiology area, now potentially contaminating that surface with germs. After the study is completed, they pick the belongings up again and put them back on the patient when they leave, potentially transporting not just the patient, but more germs. This very hard working, caring employee lamented the fact that this was not a process design that would help us reduce hosptial infections. I agreed with her wholeheartedly. 

So why doesn't this employee feel empowered enough to present a solution to this potential problem to his or her manager? This employee and his or her colleagues can redesign the system for transporting patient belongings and they need to feel that they have the wherewithal to devise a solution and put it into action. 

This is the difference between an empowered workforce and one that is not quite there yet. At Toyota, for example, when the workers find a prolem, they resolve to fix it; they're not waiting for a boss to fix it or a supervisor to give them permission to solve the issue. We need to move beyond just identifying the problem to getting in action to prove it, and fix it. If it was your daughter, you wouldn't want her to get an infection. Our staff should feel empowered to make positive changes. 

So, my messagge to all or our employees is this - when you see a potential issue and have a good solution, let your supervisor know. And, my message to all of our line managers is - encourage your staff to bring these types of ideas to you so they feel empowered to enact positive changes in the workplace.

By encouraging an open exchange of ideas by the employees who are actually doing the work and witnessing any issues, we're ultimately moving our organization to a continuous quality improvement model, and this is where we need to be. This model first focuses on the person being served (the patient), then recognizes that you get to oustanding performance by designing systems, then emphasizes measurement, teamwork and finally employee empowerment.

What do you need to feel empowered to make positive change? Do you believe you have the support to bring ideas for improvement to your managers? I welcome your feedback on this very important topic.

Finally, this is a week of religious reflection and celebration and I wish our Jewish and Christian staff members a peaceful and happy Passover and Easter.

It’s Not Easy, Being Green…But It's The Right Thing To Do

Over the past several months, I’ve talked a lot about taking care of the healthcare needs of the community and providing care that we would expect for our own loved ones to ensure a better, healthier future. You’ve also heard me talk about “doing the right thing” for our patients. This week I’d like to talk about how GBMC is doing the right thing in another way – by being “Green.” We have quite a robust Green Team at GBMC made up of a wide variety of employees who are helping to create a brighter future not only for our community, but for our planet.  We celebrate Earth Day on April 22 and our team has been busy working on the second annual Earth Day event, which will be held at GBMC on Thursday, April 21.

When I first talked to the leader of the Green Team, Mike Forthman, and later met with other members of the team, it struck me that these individuals are really passionate about their efforts. And I must say that over the past two years since the team was established at the hospital, they have achieved some pretty amazing results. They have implemented energy conservation and recycling programs to reduce waste (and waste reduction is something I’m really keen on, as many of you know). In fact, I was amazed to find out that at last year’s Earth Day event, we collected 133 pounds of household batteries, 77 cell phones and 104 pairs of eyeglasses for recycling! The team also introduced healthy living options including installation of a bike rack to encourage more staff who live nearby to bike to work and, in tandem with Keith Sappington and our dietary team, healthier food options in the cafeteria, including locally grown produce.

I know many of you are looking forward to the start of the GBMC Farmer’s Market, which was first introduced last year. I’m told this year the market will be even bigger as the team collaborates with more local farmers, and some of these farmers will be on hand at the Earth Day event, so check them out! The Farmer’s Market, and many of the green activities the team participates in throughout the year, clearly demonstrates our collaboration with other community leaders as well as other hospitals throughout the state through our membership in Maryland Hospitals for a Healthy Environment (MD H2E).  

We often think of ourselves as partners in health with our community, but we’re also partners in the health and sustainability of our environment. Not only are our efforts far reaching and long lasting, but so are our actions. I’m proud of the responsibility we are taking to ensure the future health of our community…in more ways than one.  

Employees - Visit the Green Team pages on the GBMC Infoweb to learn more about next week’s big Earth Day event and how you can take part in GBMC’s green efforts.

What are you doing to be green, either at work or at home? Share your ideas!

Good vs. Fast – When it Comes to Your Care, What Matters Most?

As a society, we have gotten used to having access to the things we need, often instant access, thanks to technology and the digital revolution. Think of all of the services you deal with every day and all of the people you utilize to get through your week. What if the dry cleaner wasn’t open on Saturdays or the supermarket closed at 5 p.m. during the week? How would this limited access affect how you go about your daily lives?

Access is one of the major issues we face as we move into this new era of healthcare reform. And while many people still aren’t sure what healthcare reform or terms like medical home mean to them as individuals, they do know that they need access to care. Knowing that your usual source of healthcare (e.g. your primary care physician) is there for you and your family is of utmost importance, which is why extended hours and being able to make an appointment with your physician at 7:30 a.m. or 7:00 p.m. is so important.

At a recent Town Hall meeting, one of our colleagues explained to me how good her experience had been at a “medical care drop-in at a store” site (You know the company that I mean). I said, “It was fast,” and she said, “No, it was good. I didn’t say fast…”  She was right, I said it was fast because I was trying to point out that if you’re given a choice of 1) not being seen at all because the physician or group who knows you is not available; 2) going and sitting in the waiting room of an Emergency Department for something that isn’t an emergency; or 3) going to a place where someone you don’t know will care for you quickly, of course you’ll go for the quick scenario. But isn’t it better to see a physician or a team member who actually knows you and has your medical records, as well as be seen expeditiously? That’s what we’re building and that’s what will make the new GBMC HealthCare system different. At the “medical care drop-in at a store” facility, it’s not about the patient. If it were about the patient, it would be a reliable source of ongoing, integrated care, not episodic care.

In this country, we do episodic pretty well, but for chronic disease, episodic care just doesn’t cut it. We need to build continuous, reliable, integrated, caring and connected care – it’s virtually impossible to be connected to a system or a provider that you don’t know and that doesn’t know you.   I truly believe that what people want is the best possible health outcomes with the greatest patient experience and this can be achieved with integrated care and access. This is the direction we need to move in to address the overall wellness of our community for the future.

We are building good and fast!

We at GBMC must put all of our efforts into making a better healthcare system. It is also true however, that at some point individuals need to be better consumers. People will need to become better at looking out for their own health, and better at questioning the expected value of the care they are receiving.

What kind of healthcare consumer are you? Do you go for quick and easy or are you more concerned with receiving care from a provider with whom you have a relationship and who knows your medical history?

This Spring, Look Ahead and Move Toward an Even Better Future

Spring is a time of rebirth, rejuvenation and reflection. And while it certainly hasn’t felt like spring this past week, the daffodils are indeed popping up and trees are showing signs of buds!  Healthcare systems have a doldrums period in late winter and I’ve witnessed this phenomenon in every place I’ve been. People, especially those of us who live in colder climates, get tired of the drab and cold. Winter also brings about the virus season and generally brings more sick patients to hospital, creating a sometimes overwhelming environment. And just in the nick of time, spring comes and people feel good again, flowers come out, more time is spent outdoors. Our moods swing upward and we begin to look forward to the opportunities that lie ahead.

Spring is a good time to really focus on where, as an organization, we are headed. So, as I reflect on the past several months and look ahead at the future, I can say with confidence that we are continuing to transform our organization and the state of healthcare. This week the state of Maryland has been discussing the future of the medical home project and GBMC is anxiously awaiting the results of the state legislative deliberations around healthcare and how we can be part of the solution. GBMC, on the forefront of change toward better health and better care, is already involved in the Care First medical home project. We need to continue to innovate to make the system better for our patients, our community, and ourselves.  

A prime example of change is our Hunt Valley primary care practice. I’ve talked a lot of this GBMA practice because they are among the first to pilot the medical home model of care and break out of the “way we’ve always done it” mold. And while we are certainly not the only organization changing the way healthcare is provided, we’re at the forefront of this movement, working to deliver better care at a lower cost with a focus on wellness, prevention and coordinated patient care. All of this change will serve us well as an organization, and serve our patients and our community even better in the long term.  A definition of insanity is doing things the same way as we have always done and expecting a different outcome. So, we should all be proud of our work to do things differently.

I know that I talk a lot about primary care (it must be the pediatrician in me). Recently a number of people have asked me why I don’t talk more about specialty care. We are blessed at GBMC with outstanding specialty care, and maybe some days I am guilty of taking it for granted. In last week’s blog, I pointed out that I had had surgery at GBMC and had taken advantage of our outstanding surgery capabilities, and the fine work of Dr. John Thompson. I neglected to thank my Anesthesiologist, Dr. Lewis Hogge. I am guilty of sort of taking anesthesia for granted. Many people do. In reflecting why, it’s because as a specialty, Anesthesiology was among the first to recognize the importance of system design to get to error free care. Anesthesia is delivered by very smart, very well-trained people who work in a well-designed system. The probability of error in Anesthesia in our country is so low, we take their wonderful work for granted. GBMC is a great surgical hospital because we have great surgeons, great nurses and technicians, and also, great anesthesiologists and nurse-anesthetists.

I’d also like to share with you a wonderful example of inter-departmental teamwork sent to me from Dr. Melissa Sparrow, Clinical Director of the Pediatric ED and Pediatric Inpatient Unit – just one example out of so many that takes place every day at our hospital:

A five-day-old baby was brought to the Pediatric ED for evaluation of vomiting. Upon arrival, the pediatric triage nurse, Anna Borchers, RN, quickly recognized the severity of the baby’s illness and brought the patient back to the inpatient pediatrics unit. Anna and Pam Spencer then worked steadily for the next hour to perform a sepsis work-up. When an IV was difficult to obtain, Steve Lebowitz, a PA from the NICU, came to the Unit and was able to place an IV. Dr. Sparrow felt the baby needed to be transferred to the NICU and the NICU team, including Dr. Podraza and respiratory therapist, Richard Vazquez, hurried down to Peds where the baby was rapidly intubated and transferred.  Once the patient was stabilized, he traveled to radiology for an Upper GI, which was performed by on-call radiologist, Dr. Loralie Ma, who came in from home to perform and read the study. Mid-gut volvulus was quickly diagnosed (A volvulus is a potentially life threatening bowel obstruction in which a loop of bowel has abnormally twisted on itself) and within an hour, Dr. Jeffrey Lukish, pediatric surgeon, repaired the volvulus. Thanks to the quick thinking and teamwork of all of those involved in the baby’s diagnosis and treatment, he was eating and drinking and ready to go home within two days! Our Team delivered the care that I would have wanted for my own loved one and I am very proud of them. 

Things are moving forward at GBMC…

Enjoy the April flowers.