The Ideal Physician for the 21st Century

1
Community Health Improvement A Call to Action
Kent Bottles, MD The 2004 Autumn Health
Forum December 8, 2004
2
Lets Do It

• What is it?
• How do we do it?
• Ask a few experts.
• Take a few plane rides.
• Do it.

3
The Overarching Local Aim

• The purpose of the health care system is to
  reduce continually the burden of illness, injury,
  and disability, and to improve the health status
  and function of the people of West Michigan.

4
The West Michigan Model for Population-Based Care

• Optimal health care characterized by
• No needless deaths
• No needless pain or suffering
• No unwanted waits
• No helplessness
• No waste

5
The problem with experts

• For every expert, there is an equal and
  opposite expert. Arthur C. Clarke, 1998

6
The problem with experts

• Joshi Come to Florida, join IHI
• Berwick Chronic Disease/Governance
• Leach Have a lot of conversations
• Sofaer Grassroots
• Vasquez Grassroots
• Critser Stop selling soda in schools
• Shaver Transdisciplinary health teams

7
System/Community Competence

• A good system/community makes it hard to do the
  wrong thing and easy to do the right thing a bad
  system the reverse.
• Paul Batalden, M.D.

8
The Institute of Medicine Roundtable

• Serious and widespread quality problems exist
  throughout American medicine. These
  problems.occur in small and large communities
  alike, in all parts of the country, and with
  approximately equal frequency in managed care and
  fee-for-service systems of care. Very large
  numbers of Americans are harmed as a result.

9
The Cost of Poor Quality in America

• Hospital errors cost between 17 and 29 billion
  per year
• 30 of direct health care costs result from poor
  quality care an annual cost of 1,700-2,000 per
  employee
• The United States spends twice as much for health
  care per capita with poorer outcomes than other
  countries

10
The Impact of Diabetes in Kent County

• Current Cases 25, 271 Population 574,335
• New Cases/Year 2,297 (1,333 avoidable)
• Note the number of cases are calculated from
  national statistics and results of clinical
  trials

11
Competencies for Systems (and doctors and
communities)

• Development through diversity
• Awareness of itself as a system
• Integration of information
• Measurement
• Interdependence
• Investment in improvement
• Alignment of roles and training
• Connection with community
• Julie Mohr, Ph.D.

12
Competencies for Communities (and doctors and
systems)

• Asking the right questions
• Partnering with experts to interpret answers
• Supporting prevention
• Using cohesive forces to build community
• Supporting justice in your community
• Clarifying definitions of values justice

13
An Example of Community Competence

• Stuart Memorial Hospital
• Stuart, Florida

14
Definitions of Coalitions

• Definition 1 An unnatural act among
  nonconsenting adults
• Definition 2 A vehicle for structured,
  purposeful interaction among a set of
  organizations, groups and individuals

15
Key factors in coalition building and community
activation

• Recognition that everyone in a coalition will
  make cost-benefit calculations that determine
  whether they will stay engaged
• Membership getting the right people to the
  table, at the right time
• Engagement maximizing contributions and
  commitment
• Leadership that facilitates rather than controls
• Balancing dialogue and action

16
North Karelia in Finland

• Focus on nutrition, tobacco use, exercise
• Decreased heart attack deaths by 70
• Decreased lung cancer deaths by 70
• Male life expectancy increased 65-73 yrs.
• Mayo Clinic CardioVision 2020
• WSJ, January 14,
  2003

17
North Karelia in Finland

• Stubborn persuasion. No power.
• What weve done better than the US is weve
  managed to get the whole community involved.
• Dr. Pekka Puska leafleted markets
• Dr. Pekka Puska on local TV
• Yellow cards to record BP

18
North Karelia in Finland

• Alter local diet (from dairy and sausage to
  greens food for animals).
• Per capita vegetable consumption per year from 44
  pounds to 110 pounds.
• Per capita berry consumption tripled to 143
  pounds per year.
• Dairy industry negative ads in newspaper.
• Half number of cows compared to 1970.

19
Why is it so hard to activate a community to be
healthy?

• Health poorly defined.
• Communities in disarray.
• Biomedical model language insufficient to task.
• Biocultural model language may be required.
• Getting started in uncertain environment.
• Leadership no ones day job, nonprofit politics.

20
Health

• Health does not seem to require the absence of
  disease or illness as a necessary condition, but
  it is not clear that this absence is by itself
  sufficient to define the nature of health.
  Caplan
• Health is an enigma Gadamer
• Health is a state of complete physical, mental,
  and social well being and not merely the absence
  of disease or infirmity. WHO

21
Disease vs. Illness

• Illness, in short, is never wholly personal,
  subjective, and idiosyncratic, nor is disease
  wholly objective, factual, and universal, but
  both take on their specific, malleable,
  historical shapes through the mediations of
  culture. David B. Morris

22
Whiplash Pain and Culture

• Lithuania no car insurance, no intractable neck
  pain and lingering headaches
• Norway car insurance, 70,000 person organization
  for neck pain, headaches
• Cultural forces at work in reinforcing pain
  dysfunction include insurance, self-help groups,
  class-action lawsuits, powerful patient
  organizations.

23
Pediatric and Adult Asthma Network of West
Michigan

• To stop all asthma deaths, we have to get the
  best information into the hands of patients,
  doctors, teachers, pharmacists, employers, family
  members, respiratory therapists really
  everybody in the community who comes into contact
  with asthma patients. Karen Meyerson, Grand
  Rapids Magazine, November 2004

24
Pediatric and Adult Asthma Network of West
Michigan

• Health-care organizations like Saint Marys,
  which gives us office space and administrative
  support, Spectrums Healthier Communities, which
  gives us a generous annual grant, and the Medical
  Education and Research Center, which has really
  taught us how to analyze our evaluation data
  are all really important, but most of the
  essential care happens in the community, not the
  hospital. Karen Meyerson

25
Community Major Site of Health Care Green,
et al., (2001) NEJM, 3442021-25

• 1000 adults living 1 month
• 800 report symptoms
• 327 consider seeking care
• 217 seek care (physician)
• 65 visit complementary/alternative provider
• 21 visit hospital outpatient clinic
• 14 receive home care
• 8 hospitalized

26
Wisdom of Crowds

• Francis Galton believed in selective human
  breeding because of the stupidity and
  wrong-headness of many men and women
• 787 people at county fair guessed wt. of ox
• Mean of the guesses was the collective wisdom of
  the fair crowd 1,197 pounds
• Ox weighed 1,198 pounds

27
Wisdom of Crowds

• Diversity each has different information.
• Independence no groupthink.
• Decentralization specialization and local
  knowledge.
• Aggregation mechanism to turn private judgments
  into collective decision.

28
I had a strong belief that what is possible
cannot be determined by opinions, but only by
attempt.

• Dee Hock

29
Given the right circumstance, from no more than
dreams, determination, and the liberty to try,
quite ordinary people consistently do
extraordinary things

• Dee Hock

30
To Live Divided No More

• Stages of Facing Reality
• The data are wrong
• The data are right, but its not a problem
• The data are right it is a problem but it is
  not my problem.
• I accept the burden of improvement