Or, then again, maybe NOT nurses in the lead...

(continuing my last post)  The first problem in any problem  should be the "problem problem" -- or, are we asking the right question?    While nurses may be better positioned than doctors to reduce costs or increase safety of health care starting right here,  that still doesn't mean they know anything about leadership.

And, given the AMA's response and leadership within their own ranks,   it is likely that physicians will in fact stubbornly and strongly resist nursing leadership on what doctors think is their own turf.

So let's fall back and ask a different question.   It seems to require both physicians and nurses to create institutional health care.  Nurses have broader but shallower knowledge.  Doctors have narrower but much deeper knowledge.  Both groups have a strong stake and therefore a strong bias.  So, which one should lead?

How about "neither one!"  Both groups currently have substantial issues in trusting the other side's relevant competency and intentions.    And,  "leadership" should be about facilitating a solution, not dictating a solution.     So,  what we have here is a need for impartial third-party mediation and facilitation.

Even if doctors are experts at doctoring, and nurses are experts at nursing,  neither group is expert at group process facilitation,   mediation,   reconciliation,  etc.    There are people, however, who ARE in fact expert in those areas,  who know little about health care.

This seems eerily reminiscent of the late 1960's and 1970's when "only doctors could be hospital administrators".     After much emotional debate,  doctors finally let go and admitted that running a hospital where medicine was practiced was not,  in fact,  medicine, but was administration.

I'll put on the table the assertion that running a good meeting and achieving some kind of sufficient consensus to move forward is not "medicine" or "surgery" either.  Nor, these days does it appear to be an activity that professional politicians engage in.     The arts of mediation, facilitation,  and leading a group of warring factions into a successful mutually-advantageous solution takes, I would suggest, as much skill as nursing or medicine or surgery.  It certainly take a great deal of specialized knoweldge of a type not currently taught to doctors, or nurses, or MBA's, or hospital administrators. It also takes diplomacy and the ability to be taken seriously by all sides as being an honest, impartial broker.

Even if nurses or doctors have a lot of experience with such roles, there is little chance they will be taken as "impartial" by the other stakeholders.  And, for that matter, taken from outside the system, who is to say doctors and nurses won't work out a sweetheart deal where they all get richer but patient care doesn't improve in quality, improve access,  or decrease in cost?

There are other major stakeholders here with "skin in the game."   The Leapfrog group and business interests have a strong need to reduce net costs to business.  I'm not suggesting it, but a single goal like that could be achieved by letting all sick or injured employees die as rapidly as possible before they consume expensive services.   One cigarette company actually presented the case to a one country that, with cigarettes widely used,  total costs would go down because everyone would die before they exhausted the retirement system funds.      In point of fact, business has a legitimate need, but no one would trust THEM to lead the discussion either, given a number of high-visibility cases where business seemed to only be out for business, at the clear expense of human beings.

Information Technology companies and departments are scrambling to volunteer to help reduce costs, although initially it appears the effort will substantially increase costs and payrolls.  Few people want to trust them to be impartial, unbiased leaders who focus primarily on keeping people healthy.

The group from public health has the longest standing concern on record for large-scale population health,   but some consider public health to be too academic and out of touch with reality,   some think public health is biased in favor of the poor,  and some think public health considers all corporations and business (and jobs) to be the enemy,  and wouldn't trust THEM to lead the effort.

So it looks like we may need to "grow our own" cadre of meeting facilitators and reconcilers and diplomats for this need.

I'd assert one thing that's just crucial.   There will NOT be a stable solution with high flexibility,  low costs, and high quality care until and unless doctors and nurses and IT and business and public health people all get on the same page and actually reconcile their differences and establish earned and justified trust in each other's intentions and expertise within their own areas of practice.

Any group  that could get a local concentration of power and jam "their solution" down the throat of the other parties might win in the very short term, but would suffer in the long term.

So, above all, the purpose of interactions between these groups has to focus heavily on healing the rift between them.    Solutions to procedures and practices will FOLLOW healing and become feasible only in a climate of earned trust.

So, yes, we need healers at the helm.  Not healers of individual humans in the role of patients, but healers on a larger scale between organizations and very different and hostile cultures.

I'll take that as a working hypothesis, that what we need is organizational-scale healers,  and use subsequent posts to examine whether the idea of "raising our own" is feasible,  or whether we can find such people somewhere on the planet,  or whether we have exemplars we could follow but simply no cash behind the effort, say in programs in "mediation" and "conflict resolution",  or what.

It is certainly clear that if we had some extra expertise in that area, the various local, regional, state, and Federal governments could sure use some of it as well.   The skills and processes and frameworks required to "bring people together in hard times" seem to be totally lacking in Washington and Sacramento and Albany these days,  let alone in the mid-East or India-vs-Pakistan, or India-vs-China, or the Koreas,  or in religious battles between Jews, Christians, Atheists, Moslems, Hindus, etc.

Clearly this would take a lot of education and cost a lot of money.  So, frankly, is computerizing the entire Electronic Health Record of the country, and it's not clear that EHR's by themselves would actually fix much, net, all things considered including disruptions due to implementation and due to getting doctors and nurses and IT and insurance companies and hospital administrators back into power struggles over who does the work, who takes the pain,  and who gets the benefits.

So far, the track record of installing EHR's in a landscape with low trust and poor working relationships between groups has not been promising at all.   Most don't succeed, and of those that are deployed, it's not at all clear that, if given the choice,  the people there would elect to do it all over again,  looking back on the true costs to get there and the true benefits delivered.

Whereas it is very clear that improving the working relationships between these groups would tremendously lower the burdens in considering rearranging processes and adjusting work flow, etc., in a way that no imposed solution could ever possibly accomplish.

There IS one way to lower the high costs of hospital-based services right now, and it is becoming increasingly popular.   It's called "medical tourism" and it means that people, and now insurance companies, have run the numbers, tried it, and found out that it's possible to fly to some foreign place like Dehli in India,    get extremely good care for some operation,   get resort-quality accomodations with servants,  and fly back home, all for a tenth of what it costs to get the exact same operation done in the US system.   Example:  knee replacement surgery in Detroit: $44,000.   Exact same operation in a hospital accredited by the same Joint Commission in India?  $4,000.   That's in a hospital where everyone speaks Engish and the nurse to patient ratios are much higher than they are in the USA.

So, here's the deal.  If the US does not get its act together soon,   the trickle abroad will change to a flood, and that means that hospital after hospital in the USA will go out of business, and EVERYONE will be out of jobs -- nurses, doctors, and administrators.     But,  just as we seem to love foreign cars these days, we may all love foreign health care for the same reasons -- low cost and high quality.

Sadly, about then, if the dollar keeps falling,  no one will be able to go abroad except the very wealthy.    And the final state of man will be worse than the first.

As Microsoft Chairman Bill Gates said in the Wall Street Journal yesterday,  the things we really need to worry about are "pandemics and bioterrorism".    So far we're not addressing either one.

I'd submit that leaving the "health care system" unrepaired in the US will destroy what's left of the system here, then price us out of care abroad, and in the resultant third-world disease-ridden consequent society,  what's left of business will go abroad as well.

On the other hand, solving the problem of generating a Service Corps of qualified facilitators, mediators, and conflict-resolvers could fix far more than just health care issues -- they might turn to fixing our businesses and economy and social divisions and hostilities with other countries and cultures as well.  It may be time to start a new branch of our UNARMED Services.