Lewis G. Sandy, MD, MBA, Executive Vice President
The Robert Wood Johnson Foundation
Discussants:
Linda A. Headrick, MD, MS,
Generalist Physician Initiative
Richard D. Krugman, MD, MS
Interdisciplinary Generalist Curriculum Project
Cynthia A. Zane, RN, EdD
Partnerships for Training
I'm delighted to be here this morning, addressing a group committed to primary care, to transforming health professions education, and to the future. You people in philanthropy spend a lot of time talking about the future, thinking about it. As Ray Bradbury said, "I don't try to describe the future. I try to prevent it." Another view of the future, perhaps more appropriate for a primary care audience is the view of Merelene Cornish, who said, "Our day will come is another way of saying you get yours."
Before we consider health professions competencies and the future, I'd like you to think another group of professionals: Navy SEALs Sea-Air-Land Teams or SEALS, trace their history back to the first group of volunteers selected to clear obstacles from beaches chosen for amphibious landing in World War II. SEALs are trained to conduct special operations, unconventional warfare, foreign internal defense, and clandestine operations.
In the terrific best-seller, The Perfect Storm, Sebastian Junger describes the capabilities of the Air National Guard equivalent, the pararescue jumpers, or PJs, as follows: "They parachute into the ocean at night with inflatable speedboats, they parachute into the ocean at night with scuba gear and go straight into a dive. They deploy from a submarine by air-lock and swim to a deserted coast. And finally, once they've mastered every conceivable battle scenario, they learn something called HALO jumping. HALO stand for High Altitude Low Opening; it's used to drop PJs into hot areas where a more leisure deployment would get them all killed. In terms of violating the constraints of the physical world, HALO jumping is one of the more outlandish things human beings have ever done. The PJs jump from a height up-as high as 40,000 feet--where they need bottled oxygen to breathe. They leave the aircraft with two oxygen bottles strapped to their sides, a parachute on their backs, a reserve chute on their chest, a full medical pack on their thighs, and an M-16 on the harness. They're so high up that they free-fall for 2 or 3 minutes and pull their chutes at a thousand feet or less. That way they're almost impossible to kill.
Junger's book describes the harrowing story of the PJs dispatched for rescue at sea during the October 1991 storm of the century. Now, I hope none of you has ever had to have been rescued at sea, but imagine if you were, and imagine the sight of a group of Navy SEALs in a rescue chopper, or in the water, or placing a rescue line around you. What would you see? You'd see a group of people who have devoted their lives to the task at hand, who have trained for this and other scenarios like this for years, who have extraordinarily high standards, and, above all, who are competent to perform the task of saving your life.
Competence; mission; performance. Groups like the PJs and the Navy SEALs are superb examples of organizing education and training around competence, which leads me to the three key messages of my talk:
Message 1-the changing nature of health care organizations means the future of primary care is in its superior performance, not ideology; Message 2-superior performance requires competence around technology, organizations, and people; Message 3-health professions education needs to evolve by a) emphasizing performance; and b) organizing around performance-developing experiences.
I don't need to remind this group about the turbulence in the health care marketplace and the changing nature of health care. I do think that where we are in September 1998 is, as Winston Churchill said, "not the beginning of the end, but the end of the beginning." The transformation of health care from a cottage industry, was well described in the final chapter of Paul Starr's book, The Social Transformation of American Medicine, titled "The Coming of the Corporation." Now one cannot predict the exact organizational forms and lead actors in this drama-12-18 months ago Columbia/HCA was a fearsome giant on the hospital scene, and Oxford was the darling of Wall Street, so times change. Nevertheless, we are at the end of the era of debate over whether health care will go corporate; the only questions are how fast, and in what way. As a result, it is inevitable that the future health care workforce will be deployed by and within organizations. Therefore, one can turn to an understanding of organizations and how they function to look for the required competencies for success. And one clear axiom is that organizations prosper in the long run by delivering superior performance.
The effective delivery of primary care will be, in my view, a core competency of health care organizations (of any scale). Successful health care organizations will effectively deliver "integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community."In addition, health care organizations will be differentiated along some measure of performance, such as price, quality, service, or therapeutic philosophy, increasingly customer focused. Look, for example, at the Pacific Business Group on Health Value Check, or the Pacificare Quality Index, both of which rate medical groups on key performance characteristics. To deliver on and improve these performance measures, health care will need an effective primary care function. This is in contrast to Harvard Business School's Regina Herzlinger, who has described a future of "focused factories" that do one thing, such as hernia repair, or diabetes care, well. I do not think this is the future for most of health care, precisely because people want "integrated, accessible" primary care, and also because of the growing prevalence of chronic disease and co-morbid chronic disease.
Let me now turn to the specifics of competence-the "What" and the "How" of superior performance. What are the competencies required for the future? I think this audience is probably familiar with the various cross-disciplinary and intra-disciplinary descriptions of core competencies and I will not repeat them here. I would suggest that the existing work that I've seen describes what I would call "first order competencies." These are the basics of competence, often generic across disciplines, albeit with different emphases. Examples include the work of the Pew Health Professions Commission, which will shortly come out with 21 competencies for the 21st century; John Noble's work cited in the IOM report that describes core competencies across internal medicine, family practice, and pediatrics, and the new COGME report. In thinking about this, I've begun to think about what I would call "Second Order Competencies." These build on the first order, competencies are required not for basic, but for superior performance. I would suggest three domains-technology, organization, and people.
Technology-imagine a primary care group that had effectively learned to leverage hardware and software to deliver primary care. These technologies include not only the usual suspects such as computers and the Internet, but also the emerging fruits of generics and the software of guidelines, practice profiles, Cochrane collaboratives, expert panels, and quality information, among others. Peter Drucker, the management guru, wrote recently in Fortune magazine about information technology, or IT, and that the coming revolution would be in the I in IT, not the T.
The second, second-order competence is organizational competence, or the effective leveraging of systems of care. For example, a multispecialty group in Southern California, HealthPartners, combines mental health and primary care professionals into their primary care practices to efficiently manage ambulatory utilization. They have a program for dying patients that provides bereavement counseling for families as the patient is dying, to provide holistic end-of-life care. Another example, Paul Bataldan from Dartmouth is working with practices in New Hampshire on the "micro-unit" of health care to track and improve primary care. Linda Headrick may want to comment as well, but these practices are organized from the primary care function out, not from the disciplines or the organizational chart, to actually deliver improved care and caring. The ability to analyze and improve practices within organizations will be a hot commodity in the future.
Finally, people. You all know the importance of interpersonal skills, cultural competence in primary care. I think an emerging second-order competence is what I term "rapid deployment of the therapeutic relationship." In the current context, clinicians will not have as much luxury as in the past to develop relationships over time. We are in an era with less time and less trust and, therefore, the skilled clinician needs to build that bond, that therapeutic relationship, in ten minutes, not 10 years. Frank Davidoff of the American College of Physicians wrote a few years back that surgeons have trained and worked in the dog lab, why haven't internists worked in the "interviewing lab"-good idea.
So that's the What of superior performance-first-order competencies as a base, second-order skills in technology, organization, and people. Now for the "How"-how do organizations train their people to deliver superior performance? To understand the How, I think we should benchmark leading organizations, such as General Electric, Hewlett Packard, Fuji, Xerox, the McKinsey consulting firm, that have developed the people processes for superior performance. In a fine book related to this subject called Built to Last, Jim Collins and Jerry Porras, two Stanford Business School faculty, found that the world's best organizations create "cult-like cultures" that recruit key people with great care, and create a "tightness of fit" between individuals and the organization in terms of values and outlook.
These organizations, in the words of a Fortune magazine article, "make the soft stuff hard." They hold to the following standard of leadership-"influencing human behavior in an environment of uncertainty."
Specifically what do these companies do? They:
* Emphasize proper recruiting-both skills and values
* Provide varied leadership experiences
* Insist on accountability
* Support and encourage mentoring
* Organize work around teams
* Transmit values through action
This approach to improved performance in health care is in its infancy, but there are a few examples out there.
The HealthSouth corporation, the nation's largest provider of rehab services, has started a HealthSouth University to teach its workforce their integrated care model of practice. Henry Ford Health System runs a managed care college for its staff. And others are emerging.
So this is the future for effective primary care. What does this mean for health professions education institutions-can they deliver? Can they evolve toward an educational vision that supports the practice vision I've described? Well, I think the people and the programs in this room represent the leading edge of change, and so I'm optimistic. I do, however, have a two-part prescription for changing health professions education that would move things in a positive direction. First, emphasize performance, and second, create performance-enhancing experiences.
An emphasis on performance, or outcomes assessment, is beginning to accelerate in health professions education. For example, the ACGW, under the new leadership of David Leach, is beginning to develop and test competency or outcomes-based review criteria for graduate medical education. Any many educators are testing competency and delivered performance of both learners and teachers. So I think the trend is encouraging.
Creating performance-enhancing experiences will be, in my view, a more formidable challenge. To enhance primary care performance learners must learn in ambulatory care settings, exposed to multidisciplinary teams, to have rich managed care experiences. Gordon Moore's work on the Program for Quality Education, or PQE, that supports linkages between managed care organizations and medical schools, supported by the Pew Charitable Trusts and other funders, is a promising effort, as are many of the efforts you are engaged in. On the other hand, I think significantly more work needs to occur in the areas of information processing and advanced interpersonal skills training-show me a program where the graduates have been tested for superior competence, not basic skills, in these areas. I also think that, to really get superior performance in primary care, schools need to work on recruiting, on mentoring, and on true leadership experiences that build leadership capacity, not just technical skills.
So in conclusion, I have tried to argue this morning that the future of primary care lies in demonstrating superior performance. Second, I have tried to show that superior performance in primary care requires both first- and second-order competencies, especially advanced skills around technology, organizations, and people. Finally, I would like to challenge health professions education institutions to evolve into organizations that emphasize performance, and organize around performance-developing experiences. I would challenge you to begin on a journey to differentiate your program-have your goal be that when people can say so and so came from your program, a mental picture of a set of competencies that deliver superb primary care pops up. In the swirling and stormy future of health care, have your students and trainees become the Navy SEALs of primary care.