A reason to change: Shannon Brownlee

Below is Shannon Brownlee’s speech from the Avoiding Avoidable Care conference.

Thank you all for an extraordinary day. I was thinking over the highlights, reviewing what I learned, what surprised me, what made me gnash my teeth.

We learned a new word: “scienceyness,” and we acquired an unfortunate image of general surgeons: “Ugh! What is white count?”

We got a sense of sheer scope of the problem of avoidable care. We caught a glimpse of just how much is missing from the research agenda, and that at least some of our major medical journals are prepared to make space in their pages to fill those gaps.

I found out after the fact that my friend Howard Brody has written not 4 books, but 8. Eat your heart out, Atul Gawande.

From the hospital panel we now know, if we didn’t before, that some hospitals are more prepared than others to accept the burden of tackling the problem of avoidable care, and what kinds of economic interests we are up against.

And once again, I am left with yet another haunting story from Diane Meier. This time it is about an oncologist who was able to step outside his frame of reference and begin to see that even when he no longer had a treatment to offer, he had an even greater gift to give his patient. His love and his compassion.

I also heard remarkably few of the pat phrases and buzzwords that have come to pollute the discussion of health care reform in Washington. I did not hear patient centered care used as an excuse for business as usual. I did not hear prevention as the panacea to our spending problem, and I didn’t hear anybody blaming patients for overtreatment.

And I did hear only a few words of discouragement about the slow pace of change.

Really? Just think about how much the health care landscape has changed!

Five years ago Howard published an article in the NEJM suggesting that each of the specialty societies come up with a list of things not to do, and an editor says to himself, nice idea, but it doesn’t have a snowball’s chance in hell.

The next thing you know the National Physician’s Alliance has gotten the primary care specialties to come up with a list, and the next thing after that the ABIM Foundation is holding a press conference announcing nine more societies have joined the fray.

Five years ago, people told me the only problem worth worrying about in the US health care system was how to cover 40 million lives. Today, we still fighting over coverage, but look around. We are all here at this meeting.

The world HAS changed, and will continue to change, but now our task is to figure out how to make it change faster, and how to get more people willing to make that happen.

A man named Howard Perlstein, who I think is here today. Howard told me there are four conditions must be satisfied for individuals and organizations to change.

1. People need a compelling reason to change.

2. They need incentives to change.

3. They need role models.

4. They need the skills.

What Vikas and I are most interested in getting from this group is ideas about how to create two of those four conditions: We hope you will focus on uncovering the compelling reasons to change and finding more role models. Others can work on the other two conditions, creating the specific incentives and providing people with the skills. We have gathered all of you so you can know that you are not alone, that we have companions in this effort.

Two hundred years ago, on a chilly spring day not unlike this one, 12 people gathered in a room over a print shop in London and launched a movement that would change the world. Among those 12 was the man who wrote the hymn, “Amazing Grace.” He was a former slave ship captain who was now part of the small band of men and women who stopped the English slave trade.

If you think our task is daunting, let me tell you about theirs. At that time, slaving comprised about 5 percent of the British economy. That’s about the same percentage as avoidable care comprises in ours. Slaving built the great port of Liverpool, many of the grand houses of London. It supplied the labor in the West Indies that produced the sugar that the English put in their tea, and the rum the lower classes drank the way we now consume Coca-cola.

And do not imagine that economic interests were the abolitionists’ only obstacle. At the end of the eighteenth century, over three-quarters of the world’s population lived in bondage of one form or another, members of a global economy that was largely based on forced labor, indentured servitude, or outright slavery. In parts of the Americas and Africa, slaves outnumbered free persons.

Today, it’s almost impossible to imagine such a world, but in those days, as historian Seymour Drescher puts it, “freedom, not slavery, was the peculiar institution.”

Yet the British slave trade, a huge and hugely profitable enterprise, was abolished in the space of 50 years because of the earnest and concerted efforts of a committed band of activists. Long before the age of the Internet and Facebook, television, faxes and cell phones, the abolitionists were able to accomplish the single most critical task of any group of activists: they changed people’s minds.

Am I comparing the problem of avoidable care to the slave trade? Hardly. But I tell you this story to illustrate the power of ideas. I tell you this story to give you courage for the task ahead.

Right now, today, what lies ahead are some inspiring examples of institutions that have already begun to use those four principles, a reason to change, incentives, role models, and skills, to extract waste, and avoid avoidable care – and focus on patients. We’ll hear about payment mechanisms that will necessary but not sufficient to bring about the change. And the role that purchasers and patients can and must play.

Before that, it’s my pleasure and truly an honor to introduce Dr. Bernard Lown.

I could get off easy by saying Dr. Lown needs no introduction. Or I could take a different route and simply list all of his accomplishments. But if I did that we would not get to the rest of the program, because Dr. Lown has done more to improve the plight, not just of patients, but of all citizens of the world.

International Physicians for the Prevention of Nuclear War, an organization he helped to create, was awarded the Nobel Peace Prize in 1985 for its work against nuclear proliferation. He is the inventor of the external defibrillator. He was a co-founder of Physicians for Social Responsibility. He got heart attack patients up and walking, contravening received wisdom of the day that what patients needed after an acute MI was lots of bed rest. And if you have not read The Lost Art of Healing, do. And assign it to all your students.

The list of Dr. Lown’s extraordinary accomplishments goes on and I’m sure I have missed some of the most important ones. But what I want to convey is a little bit about Dr. Lown as a person.

I know that he is uncommonly courageous. As a medical student he stood up to the injustice of racism of the 1940s that pervaded not just the American south but also the halls of academic medicine. I’ve had the privilege of spending some time with Dr. Lown, and the man I encountered has a fierce intelligence that can’t be masked. Of course, brilliant people are a dime a dozen here in Boston. Just ask them. Not so many have Dr. Lown’s ability to see what others don’t, to use intuition as well as logic. Few have his . . . something that’s hard to put into words, but I guess I would say he has, well, heart. He has a deep sense of compassion for the plight of other human beings. I suspect he has always known that intelligence is not enough for good doctoring. That time, love, and compassion are his greatest gifts to his patients.

But more than anything, above all else, I am struck by his generosity of spirit.

And the most astonishing and inspiring thing about this meeting is to know that I am in a roomful of people who share that spirit. You embody what is best in medicine. You haven’t forgotten why you decided to become doctors, and I hope you won’t mind an outsider saying this, but this meeting is part of a larger effort, sparked by many individuals, to recapture the soul of medicine. To do that we will all need at least a measure of Dr. Lown’s heart.

I’ve said enough. Dr. Lown, thank you for joining us today.

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