Managing Change in a Sea of Change

In the last decade, big changes in the healthcare profession have resulted in upheaval, stress and burnout, new types of reimbursement, and the implementation of technology with new ways of treating patients, such as telemedicine and genetic mapping.

Consider the book Our Iceberg is Melting: Changing and Succeeding Under Any Conditions.(1) The book tells the story of a colony of penguins living on an iceberg that is melting in Antarctica, making it necessary for the group to move to another, more stable iceberg. The other penguins will not listen to the penguin that has recognized that the iceberg is unstable and tries to alert the leaders and the wise elders of the colony about the perils of staying on their unstable iceberg. Most of the penguins are of the opinion that the iceberg that they have known for so long is fine and they don’t need or want to change. The story is analogous to the common situation where people don’t want to face up to difficult problems and are confronted with decisions that may require change.

However, when several of the penguins were presented evidence (data) that convinced them that their iceberg actually was melting, they rose to the occasion and:

1. Created a sense of urgency to deal with the difficult problem;

2. Put a group in charge of guiding the change;

3. Showed the possibility of a better future;

4. Communicated their vision to others;

5. Removed obstacles to action;

6. Persisted until the new way of life was firmly established; and, finally

7. Showed that stubborn, hard-to-die traditions would not save the colony from disaster if they stayed on the unstable iceberg.

So how does this apply to our medical practices that need to adopt to change in order to survive? Change does not take place easily in the healthcare arena. Healthcare workers and leaders often are comfortable with the status quo and often resist change. However, if we listen to our patients and pay attention to data regarding new methods of diagnosis and treatment, we will be in a position to challenge the status quo.

The Changing Face of Medicine

Some examples of change that will have big effects on the healthcare profession in the very near future include telemedicine; precision medicine, and the changing role of the doctor–patient relationship in general.

Telemedicine

Telemedicine is slowly becoming accepted as a method of caring for patients without being eyeball-to-eyeball in the office or exam room. Today more than 15 million Americans have used remote medical care, thereby reducing healthcare costs by more than $6 billion.(2)

This new way of practicing medicine will consist of the virtual office visit. Doctors will be able to monitor chronic health conditions via computer. A Harvard study found that patients with hypertension who had “virtual” office visits over the Internet were able to control their blood pressure as well as people who had in-person office visits.(3) Patients in the virtual care group averaged about one fewer office visit than people in the other group over a period of six months, and they had fewer emergency department visits and hospitalizations overall. What does the future portend regarding change in healthcare? You can expect that in the future, virtual visits will become the norm rather than the exception. Virtual follow-up visits for other chronic diseases (e.g., congestive heart failure, diabetes, obesity, and benign enlargement of the prostate) also are on the horizon. In fact, many healthcare providers already use virtual care to follow 65 different kinds of chronic disease.(4)

Precision Medicine

Precision medicine uses 3D printing to create medications treating hypertension, high cholesterol, and heart disease. Ninety percent of prescribed medications are available as generic drugs and can be combined cost-effectively so patients take fewer individual medications. Imagine a patient with hypertension, diabetes, obesity, cardiac arrhythmia, and high cholesterol levels. This patient has a smartwatch or a smartphone that can record daily weight, glucose levels, blood pressure, and cholesterol levels. This information is sent electronically to a physician who makes adjustments in the medication and then transmits the information to a 3D printer in the patient’s home that “prints” a pill that is precisely designed for that patient’s condition at that time.

The new methods of data collection will soon affect the management of patients with certain cancers. Data—in particular, data stored in an electronic health record (EHR)—make personalized medicine possible. The EHR will contain clinical data such as diagnostic testing results, genetic test results, and pathology reports. The record also may include information about the patient’s individual values, preferences, and lifestyle. The challenge is to ensure that the EHR not only contains all critical patient information, but also is organized so that clinicians can use it to provide optimal treatment for the patient.

For example, consider a 70-year-old patient who has newly diagnosed metastatic, non–small cell lung cancer. He has had a test to find out whether his tumor has one or more mutations that make it sensitive to a specific drug that has been suggested by his doctor. With the accumulation of voluminous amounts of data, it is necessary that the data be organized and comprehensive and that the data can be easily accessed. The data also must be interoperable among various medical systems to make the data useful.

The Changing Role of the Doctor–Patient Relationship

Seventy-five years ago, caring and compassion were major “treatments” doctors could offer. Over time, advances in medical science have provided new options that have often inadvertently distanced physicians from their patients.

Just a few decades ago, doctors had all the knowledge and information on health. Today, thanks to the Internet, patients can be just as informed as their doctors, because they have access to the same information that doctors have. As a result, patients want to be more involved in their healthcare decisions, and that means doctors must use innovative technology, informed patient engagement strategies, and different organizational structures to drive better patient experiences. These factors can result in disruptive, rapid change that results in alterations of the doctor–patient relationship. At the same time, because of the constraints of time and increased requirement for doctors to complete an abundance of paperwork, today doctors face a healthcare environment in which patients and their families often are excluded from important discussions about how to navigate the overwhelming array of diagnostic and treatment options available to them.

In 1988, the concept of patient-centered care brought attention of the need for clinicians, staff, and healthcare systems to shift their focus away from diseases and back to the patient and family.(5) The term was meant to stress the importance of better understanding the patient’s experience of illness and of addressing the patient’s needs within an increasingly complex and fragmented healthcare delivery system.

Now there is an approach called shared decision-making, a much needed change in the way doctors speak to patients so that they work together as a team or a unit to come to a decision regarding the care the patient will receive. The process by which the optimal decision may be reached is called shared decision-making and involves both the doctor and the patient. In shared decision-making, both parties share information: the clinician offers options and describes their risks and benefits, and the patient expresses his or her preferences and values. Each participant is thus armed with a better understanding of the relevant factors and shares responsibility in the decision about how to proceed. This is a welcome change that has improved the relationship between doctors and their patients. The change did not come easily to the healthcare profession; many doctors wanted to hold on to the attitude that they knew the best way to treat a patient and that the patient’s attitude or acceptance of the treatment was of minimal importance.

According to a Cochrane review of 86 trials published through 2009, the use of patient decision aids for a range of preference-sensitive decisions led to increased knowledge, more accurate risk perceptions, a greater number of decisions consistent with patients’ values, a reduced level of internal decisional conflict for patients, and fewer patients remaining passive or undecided.(6)

How Change Happens

Lessons from the penguins begin with creating a sense of urgency. Let’s look at Alzheimer disease, which, as of 2018, affects 5.7 million Americans, a number that is expected to increase to 14 million by 2050.(7) This disease must be diagnosed early, before permanent changes occur, and then treatment solutions must be found that can reverse the tau and amyloid entanglements within the brain. Alzheimer disease has reached a level of urgency, and there must be motivation and resources to control this “melting iceberg” in American healthcare.

After alerting the masses of the problem, it will be necessary to put a team together to solve the problem. Consider the opioid crisis, which takes the lives of nearly 30,000 people every year. Powerful groups that have the clout to inform large numbers of people about the opioid crisis include organized medicine, Congress, and Department of Health and Human Services. Our message is that it is necessary to make sure there is a powerful group guiding the change—one with leadership skills, credibility, communications ability, authority, analytical skills, and a sense of urgency.

The change process begins with understanding, expecting, and accepting that change in healthcare is inevitable. Doctors have to know that the skills they learned in medical school and their training programs soon become obsolete. Rather than resisting or avoiding what doctors interpret as looming disruptions, it is important to proactively engage and embrace change. Whether it be an organizational shift, a change in business models being adopted, a change in reimbursements, recognizing changes in compliance, or an improvement in technology, it is important to seek to understand the goals and expected outcomes of such change. Otherwise, we just may be existing on a melting iceberg. The penguins will tell you that is an untenable situation, and change must take place in order to survive.

The next requirement for implementing change after a team has been selected is for a strategy and vision to be put in place. Once the plan is put into action, it is necessary to share with the rest of the doctors in the group as well as the staff the results, even if there are only short-term and incrementally small improvements. Measuring and monitoring outcomes of the change process are essential for recognizing whether or not the change process has fulfilled its purpose or been effective. The new ideas slowly will take hold and become strong enough to replace old traditions. It’s not easy, especially in medicine, but it can be and must be done, because the healthcare iceberg already is cracking.

Bottom Line: The iceberg and penguin story teaches an important lesson. When doctors, administrators, ancillary healthcare workers, and employees are all on the same page with regard to change, it is amazing what can happen, despite adverse conditions. Ask yourself whether you are living on a melting iceberg or an iceberg that could melt. Melting icebergs come disguised in many forms: paper charts giving way to EHR; moving from volume of care delivered to value of care patients receive; distance learning; new methods of physician reimbursement; using new technology to be part of the caring process; and use of physician assistants and nurse practitioners to provide initial care for patients. Holding on to the status quo by using antiquated and irrelevant services that are decreasing quality or not providing improvement in outcomes, or a business strategy that makes increasingly less sense, suggests that you are on a melting iceberg and you need to take a lesson from the penguins.

References

1. Kotter J. Our Iceberg is Melting. Changing and Succeeding Under Any Conditions. New York: Portfolio/Penguin; 2005.

2. Sprinkle T. Remote medical care is future of medicine. The American Society of Mechanical Engineers. https://www.asme.org/engineering-topics/articles/technology-and-society/remote-health-care-future-medicine .

3. Virtual visits and high blood pressure. Harvard Health Publishing. https://www.health.harvard.edu/staying-healthy/virtual-visits-and-high-blood-pressure .

4. McGrail KM, Ahuja MA, Leaver CA. Virtual visits and patient-centered care: results of a patient survey and observational study. J Med Internet Res. 2017;19(5):e177.

5. Gerteis M, Edgman-Levitan S, Daley J, Delbanco T. Through the Patient’s Eyes. San Francisco: Jossey-Bass, 1993.

6. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;10:CD001431-CD001431.

7. Alzheimer’s Disease Facts and Figures. Alzheimer’s Association. https://www.alz.org/alzheimers-dementia/facts-figures .