I'm struck by the degree to which conversations regarding improving health care focuses on creating large vertically integrated organizations. While it is absolutely possible that such industrial scale entities can provide very high quality care (consider Group Health Cooperative in the NW, for instance), the human aspect of what we do seems to be at risk.
There are very good studies indicating the importance of human relationship in our work. We know that 'trust in physician' is an important variable in helping people achieve the best rates of preventive care.(1)
We don't need elaborate studies to understand that discussing sensitive and difficult issues is easier when the other person is known. There are numerous studies documenting the link between continuity (interacting with the same health care professional) and quality.
I've worked with a number of industrial scale health care organizations. These groups were the ones committed to quality and willing to invest resources to demonstrate that commitment. I found that even the best of intentions were often thwarted by large bureaucracies. The very size of the organization became a massive impediment to change. Layers of managers, Byzantine committee structures. Getting things done require endless meetings, delays, and many changes died due to competing agendas.
On the patient side I saw the near universal experience of people objectified as patient and defined by their illness or 'complaint.' Most of the rules of organization functioned to protect and serve the health care work force (and didn't even do that well I might add) while suffering people were forced to repeat demographic stats again and again, were subjected to interminable waits and delays, were forced to wade through layer after layer of staff just to make an appointment.
I post for your consideration two diagrams. These are 'spaghetti' diagrams showing the movement of people in a medical practice (imagine you are looking down at a floor plan from above and watching people move around in their work - each diagram shows all the people movement for a typical patient office visit).
Figure 1 shows a typical practice with patient (circle), secretary (triangle pointing up), nurse (square), and doctor (triangle pointing down). Figure 2 is a practice that has been designed around the person seeking care (circle), and includes the doctor (upside down triangle) and support person (square).
No hypotheticals here, this was my practice of old and my new practice. To do this I had to step out on my own. The system in which I worked was and is very committed to quality and in fact invests a good deal of time and money in improvement efforts, but while they continue to do good work, they are not currently capable of achieving this level of change.
Small practices can turn on a dime, making substantive changes that dramatically improve the experience of care and quality. Working with volunteer practices from around the US we demonstrated the ability of others to do the same.
Small practices don't struggle as much with human relationship. The very structure of small practices encourages continuity and relationship. The very lack of 'call centers' and telephone voice attendants and layers of staff make small practices more personal. More personal, better relationships, better communication: these are all ingredients of better care and outcomes.
Small can be done well or badly. Big can be done well or badly. Weighing one against the other I'd bet that small is more likely to achieve meaningful interaction than big.
I'm not hot on the idea that big has to be the way of the future. Most people are not keen on big box medicine. Unlike big box stores the 'big box medicine' is more expensive, more impersonal. As a nation we need to think deeply before we commit our national resources to initiatives that encourage and support industrial big box health care.
FIGURE 1
FIGURE 2
(1)Ling BS, Klein WM, Dang
Q. Relationship of communication and
information measures to colorectal cancer screening
utilization: results from HINTS. Journal
of Health Communication. 11 Suppl
1:181-90, 2006.
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