Patients need 'pit crews, not cowboys'

Distinguished surgeon Atul Gawande, MD, MPH, saluted physician assistants during the opening session at the AAPA 2014 meeting.

Patients need 'pit crews, not cowboys'
Patients need 'pit crews, not cowboys'

BOSTON – The explosion of medical discovery that's occurred over the past 60 years has shifted the way healthcare providers work from omniscient physician-centric models to nimble, flexible multiprovider teams, with physician assistants playing vital roles.

“We have been cowboys when what patients need are pit crews,” surgeon and best- selling author, Atul Gawande, MD, MPH, of Brigham and Women's Hospital in Boston, Mass., told a packed audience during the opening general session at the American Academy of Physician Assistants IMPACT 2014 meeting.

Being a health-care provider today is much different than it was in the pre-penicillin era, when a hospital stay offered little more than custodial care, and a patient's life or death depended more on the course of disease than what a doctor did.

Since the 1940s health-care providers have defined more than 14,600 conditions that afflict the human body, discovered more than 6,000 new drugs and treated patients with 4,000 medical and surgical procedures.

“Deploy that capability town by town to every person alive and the structure we built on the autonomy of the physician's judgment is breaking under the weight of all of that knowledge and capability,” Gawande said.

The resulting increase in subspecialization among medical professionals has been a natural progression, and ensuing conversations pitting PAs against MDs are “absurd,” he noted.

When Gawande's own mother was recently discharged from the hospital following knee replacement surgery for osteoarthritis, her medical team consisted of no less than 63 clinicians – comprised of physician assistants, nurse practitioners, physical therapists and “occasionally a surgeon.”

“Team-based medicine is hard work that none of us are trained for. It requires us to set clear lines of responsibility, to track performance, to set goals and standardize our workflows, to innovate the way we work, and change and improve,” Gawande said.  “It depends on putting the right people in the right places, and that is not defined by our licenses.”

Sickest 5% account for 50% of costs

As U.S. medical costs continue to soar, accounting for 20% of the American economy, the nation's financial solvency will hinge on the healthcare sector's ability to innovate.

“Healthcare as a system is failing our society,” Gawande said. “In 10 years there has been virtually no growth in compensation for American people, because everything is being eaten up by the cost of just maintaining our healthcare benefits.”

Reversing these trends will require healthcare providers to identify and understand what happens to the sickest patients -- 5% of the population accounts for 50% or more of our healthcare costs, according to Gawande.

One such success story, Jeff Brenner, MD, executive director of Camden Coalition of Healthcare Providers in Camden, N.J., was able to do just this.

Along with a small team of physician assistants and nurse practitioners, Brenner was able to identify, map and treat the 1,000 sickest patients in Camden. These patients accounted for 38,000 hospital visits and $375 million in medical bills during a three-year period.

Brenner and his team identified facilities with the sickest patients. One such facility was a nursing home, at which the sole physician saw patients in the morning and worked in his clinic in the afternoon. If anything happened while the physician was at his office, nursing home patients were sent to the ED.

Simply employing a PA in the afternoon enabled the facility to lower costs from $5,200 per month to less than $3,000 per month.

Brenner's team has since grown to 55 people and the Camden Coalition of Healthcare Providers now has contracts with Medicare, Medicaid and United Healthcare.

“You want to be part of a workplace where this is what you're making happen. Think about the sickest patients and how you can make their care the best possible,” Gawande said. “If you're in a workplace that's not moving this way, then find a new place to work. This is the future – a future where you and I will have 63 people who don't think they're each the boss. They think you are.”

Reference

  1. Gawande A. Opening General Session. Presented at: AAPA 2014 Meeting. Boston; May 23-28, 2014.
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