Change is difficult for healthcare professionals but especially difficult in a for-profit healthcare system setting-especially those systems caring for high-risk populations.
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Change is difficult for healthcare professionals but especially difficult in a for-profit healthcare system setting-especially those systems caring for high-risk populations. Many medical care providers may not realize their aversion to change except after further analysis and reflection.
Admittedly, how we, as people, resist change and how we recognize our own (internal) oppositions is a complicated matter, but it is an even more significant (and morally obligated) hurdle for medical care providers. In his article Slow Ideas, Atul Gawande, MD, makes a critical observation about delayed acceptance of this analysis. One critical question he asks is why some innovations take off, while others do not.
Gawande states in his article, "Maybe ideas that violate prior beliefs are harder to embrace." He hypothesizes that it is difficult to end an activity without any data to back up the claim for why it may not be the best method of execution. He further hypothesizes that without trust and respect, it is difficult for individuals to listen to the enforcer of any new idea.
Let’s take the example of Hahnemann University Hospital in Philadelphia. In 2012, Hahnemann was owned by Tenet Healthcare Corporation, a for-profit entity under a collaborative teaching relationship with Drexel University College of Medicine. The operating room resources allocated for pain management services at this hospital were scarce, and the patient population with substance abuse disorders was both increasing and racially and socioeconomically underserved.
The challenge was clear: How to move the needle when the resources were little to nil and the escalating opioid crisis and demands of patients and physicians were rising. The infrastructure of the facilities was challenging and very few resources were offered to operate the pain center. Moreover, the pain services were often disorganized since they were siloed and leadership was not clear on how to provide services at the hospital. Given this situation, it was a challenge to build a pain center that would serve to educate while also treating patients in a sound, evidence-based manner.
Many of the pain patients treated at this hospital had a pre-existing history of opioid substance abuse disorders due to the overwhelming prevalence of these substances in the surrounding Kensington neighborhood, which was known as “needle park” (a local gathering area for intravenous drug users and illicit and prescription drug users).
In order to improve the health system, in 2012 Anita Gupta, DO, PharmD, MPP, was recruited from the University of Pennsylvania Department of Anesthesiology to develop the pain services program, stabilize the health system services for the hospital, to educate medical students and residents, and establish clinical patient services for the anesthesiology department for this high-risk population during a rapid evolving opioid crisis from 2012-2017.
Even as the crisis grew she and her team continued champion initiatives at the hospital that engaged nurses and internal and external faculty on how to mitigate the opioid epidemic through collaborations with the American Society of Anesthesiology and various non-profit organizations.
Over the course of five years, by implementing the ideas in Gawande’s article, the pain program went from dismal circumstances to international recognition that included awards from non-profit organizations, job placement in in top tier programs, Medline indexed publications, and multiple grants from public and private organizations.
In May 2017, however, Tenet Healthcare sold Hahnemann to a private equity firm. Following this acquisition, the onsite academic-based anesthesiology department pain center closed. The loss of the in-system pain management center presented many challenges for patients and for education and training in an academic medical center in the epicenter of a public health crisis in Philadelphia.
Philadelphia continues to have significant need for treatment of substance use disorders, pain and need specialized anesthesiology trained pain providers. According to in the CDC’s 2016 “Guideline for Prescribing Opioids for Chronic Pain,” the treatment of chronic pain with or without opioids requires intensive monitoring, counseling, and reassessment. Therefore, having anesthesiologists on-site who are specialized in pain management and treatment and can respond to the evolving crisis is a necessity.
These responsibilities explain why many primary care providers, both inpatient and outpatient, rely on pain management providers for chronic pain treatment. The need to refer patients out of the system for pain management presents multiple new barriers to patient care: finding a reliable provider for the referral, ensuring that the new provider participates in a patient’s insurance plan, transferring medical records and prior treatment information, and the geographic separation of many health systems. These barriers unquestionably make it more difficult for patients to responsibly and safely find treatment for their pain.
The health of a population is the responsibility of not only the community but the primary care providers of the region. It is our duty to address how we can best care for the people and patients we work for (not with). Only then will we be able to create a sustainable healthcare system in which we are able to address the need of a community despite the lack of adequate resources. If we do not open our minds to the “ideas that violate prior beliefs” that Gawande describes, we will perpetually be cycling through situations such as the one at Hahnemann University Hospital.
The current opioid crisis is a perfect example of Gawande's belief system of how to develop a solution to under resourced health challenges. In 2001, there was a national effort to ameliorate the undertreatment of pain: The Joint Commission made pain the "fifth vital sign," and there was a strong push for the aggressive treatment of pain.
The work being done to solve the opioid crisis is challenging. Solving this crisis requires diligence, patience and time. We must support voices and champions that move Slow Ideas forward that exist to serve the community as poignantly illustrated here. And we must accept change according to current belief systems, even if they may "violate prior beliefs” as Gawande’s theory states.
Gupta is a professor in the department of surgery at Rowan School of Medicine in New Jersey, Parikh is a student at Princeton University, Dukewich is a student at the Drexel University College of Medicine and Makam is a student at Columbia University.