A Medical Economics Web Exclusive

How internists can help fix the system

They should address the root problems that lead to most medical errors, says the current president of the ACP-ASIM.

Of all the issues internists have on their plate, says the leader of their specialty, none is more important than that of reducing medical errors.

General internist and geriatrician William J. Hall, president of the American College of Physicians-American Society of Internal Medicine, strongly endorses the Institute of Medicine’s latest report. The IOM calls for fundamental restructuring of the US health care delivery system to safeguard patients and improve care.^*

Hall is chief of the general medicine/geriatrics unit and director of the division of geriatrics at the University of Rochester (NY) School of Medicine and Dentistry’s Strong Memorial Hospital. He’s board-certified in internal medicine, geriatrics, and pulmonary disease.

Senior Editor Ken Terry recently interviewed Hall, who assumed his presidency last April, about his priorities for the ACP-ASIM’s 115,000 members.

Q: The new IOM report says that reducing errors isn’t a matter of getting doctors and health care workers to try harder, but that the system itself has to be restructured to create an environment for reducing errors. Do you agree?

A: Absolutely. The hardest thing about discussing this patient-safety issue is that it isn’t as simple as finding the few bad-apple doctors and throwing them out. Doctors are used to thinking of themselves as fairly autonomous, captains of the ship and all that. We do have a role in error reduction, but we’ll make a substantial difference only in how we relate to the other parts of the system. And there are many flaws in that system right now.

Q: How can the ACP-ASIM help improve patient safety in ambulatory settings?

A: We can try to understand much better how you translate this IOM concept of improving the system to the ambulatory scene, particularly at the critical points where there are likely to be problems.

These problems generally occur at points where there’s a handoff: In the interface between the generalist and the specialist, for instance, or between the writing and filling of a prescription, where there’s a potential for something to be lost in the translation. That’s where we’ll make our contribution. We’re not going to prevent the wrong leg from being cut off, or other extreme, but fortunately rare, events.

Q: Does the ACP-ASIM support the work of the Institute of Healthcare Improvement on clinical office re-engineering?

A: When [IHI President] Don Berwick gave the keynote speech two years ago at our annual convention, he laid down the gauntlet for our organization. He said, "You have the power to influence the health care system in any way you wish. All you need is a sense of purpose and relentless drive."

I share leadership in this organization with Bernie Rosof, chairman of the Board of Regents. Our first official action after I took office was to visit Don Berwick. That says what we think of IHI.

Q: Many physicians resist the idea of practice guidelines and a systematic, population-based approach to health care. How do you break through that?

A: There are some generational differences among doctors. In general, younger doctors have been educated more about the system approach, so they’re more attuned to it and more accepting of it.

I’m convinced that the essence of what doctors do is in the individual relationship between us and the patient. Many physicians are protective of that interface. What we need to do is change the paradigm and say, "We’re going to not only protect it, but make that interchange more valuable to both parties by changing the systems that have impaired it."

Many doctors complain about the bureaucratic hassles they encounter, particularly related to Medicare administration. But unless we take charge of and develop these systems of care delivery, that precious doctor-patient interface is going to shrink even more.

Q: Is information technology essential to changing most of the aspects of the system that need to be changed? Or can a great deal be done to improve clinical processes before you even get to IT?

A: I think both are important. IT is a necessary component of system change. But let’s say we had the most computerized system available: Would it guarantee added value in the physician-patient relationship? I don’t think so.

For IT to really catch on in physician offices, payers need to reward us for excellence rather than punish us for lack of excellence. But it’s still going to take more than a decade for the paperless chart to totally evolve in the office setting.

Q: The IOM also suggested the need for more nonvisit care, including e-mail consults. Is this realistic, considering that most doctors don’t get paid for it?

A: No. Nonvisit care initiatives are trying to expand the patient care relationship while maybe changing the definition of that relationship. There are ways of relating to patients that don’t require touching them, and some of those ways are electronic. But currently there’s no way of being paid for that.

I feel this in my own practice, which is now almost exclusively the care of older adults. On a time basis, I get paid for very little of what I do that’s important: meeting with families, discussing advance directives, trying to perceive people’s values.

That’s what the IOM report is saying: Let’s get back to what medicine is all about, but let’s use the modern technology to help us do it right. The report really screams at us to redevelop the personal relationship that we all thought we understood.

Q: If doctors were reimbursed for e-mail consults, could they be useful for handling minor patient concerns?

A: E-mail will be additive, but it’ll never substitute for one-on-one contact. Just as most experienced doctors depend on the telephone to assess the severity of patient symptoms, the same thing could be done through an e-mail system. But it’s an enormous educational challenge for both the patient and the physician.

Where I think e-mail will have greater value is in systematic reminders. Things that fall through the cracks now can be automated. For example, a doctor could e-mail a patient to say, "It’s time for your annual physical, and here are four or five things that need to be done."

Q: While online health care promises to transform medicine, the hospitalist trend is already having a big impact. In the long run, will that trend reduce internists’ role in inpatient care?

A: We don’t know yet. We’ve encouraged the hospitalist organization, the National Association of Inpatient Physicians, largely because so many of our own young members have been choosing this as a career. We’ve mutually agreed that this organization won’t support mandatory handoffs of patients. We couldn’t participate in a system that denied primary care physicians the right to follow their patients in the hospital.

But we know that with the increasing complexity of medical care and the heavy demands in the office, it sometimes makes sense to have a specialist in hospital medicine provide the care–as long as the lines of communication with the primary care physician are safeguarded.

Q: In a panel discussion on medical professionalism at your conference last spring, one speaker forcefully made a point about the need for doctors to disclose all conflicts of interest to their patients. Should doctors be telling the patients they’re trying to enlist in clinical trials, for example, that they’re getting $3,000 for each patient they enroll? Should they tell them that the new medication they’re prescribing was pitched by detailers and explained to them at a CME conference at some lavish resort? To what length should physicians be expected to go in disclosing this sort of thing?

A: They need to be very explicit about it. First, if that’s really where a physician is getting his information, we need to work with him. There are much better ways of getting information than that old-style, "let’s go to Palm Beach for the weekend" kind of thing. He can come to our annual meeting, for example.

As an organization, we’ve gone on record that professionalism includes full disclosure to patients of any conflict of interest. If you’re doing clinical trials through a credible institutional review board, that board is going to insist that you explain your financial interest to patients in writing. The IRB movement in this country has made a huge difference in this regard.

Q: But with regard to prescribing, aren’t a lot of doctors influenced by detailers from pharmaceutical companies?

A: I can’t generalize for 115,000 doctors. But we like to think our organization includes people who have spent a substantial amount of time understanding their art and craft.

We will increasingly provide opportunities for education much closer to the point of clinical decision-making. We’re about to make all of our educational products and guidelines downloadable to Palm handhelds and to other information devices as they evolve, and I think this is going to help solve some of these issues.

So if the problem is that the only access a doctor has is to what is arguably a biased source, we’re investing millions of dollars to create alternative avenues of information.

^*See "The new IOM report: Will it change your practice?" Aug. 6, 2001.

Ken Terry. How internists can help fix the system.

Medical Economics

2002;6.