Learning about How to Change Care Delivery through Experience in Practice
My personal goal to link practice and population improvement strategies had its roots in the orientation I brought to Dartmouth and carried with me through medical school and residency. I was lucky to grow up in Washington, DC. My father was a lawyer and my mother a social worker. My family placed a strong emphasis on taking responsibility for those less fortunate than oneself. The late 1960s and early 1970s were a time of political activism. As a young person in Washington, we were immersed in the importance of "changing the system."
I remained interested in social and political change during my time at Dartmouth. When I decided to go to medical school in New York City to train at Bellevue Hospital, I wanted to experience medicine in one of the country's biggest urban public hospitals. During medical school, I also decided to join the National Health Service Corps (NHSC) as a way to provide service. The chance to work in the Denver Health and Hospital System during my residency at the University of Colorado only deepened my commitment to working for the socially disadvantaged.
Fresh out of residency, I was eager to put into practice all that I had learned. However, I wasn't able to start my work in the NHSC because I wanted to be with my wife as she began her residency in Rochester, New York. I found a position with the Elmwood Pediatric Group while I waited for my service to begin. The Elmwood Group had a long tradition of practice-based research. Burt Breese and Frank Disney popularized the use of the office throat culture in ambulatory practice (Breese 1969), and over the years, hundreds of scientific papers emanated from the partners. After I began my NHSC service at the Anthony Jordan Neighborhood Health Center, I continued to spend parts of days and weekends at the Elmwood Group.
There was a striking difference in the environment of the private practice and the Jordan Health Center. At the neighborhood health center, appointments were scheduled twice a day in blocks, once in the morning and once in the afternoon. Mothers and children waited for hours in a cramped waiting room devoid of pictures or toys. At the Elmwood Group, we saw many more patients, equally complicated cases, in a schedule that ran on time. At Elmwood, I would see poor kids with asthma whose disease I could manage much more effectively than I could at the health center because it was easier to develop an effective relationship with patients in a system that ran efficiently and that communicated a sense of caring. In short, I was struck by my inability to produce the same outcomes (even though I was the same person) working in two different systems. It was simply unavoidable not to recognize that my effectiveness as a clinician depended on the system in which I was working.
I also discovered that by focusing on what patients deserve, I could change the system. After I was named director of pediatrics at the Health Center, I took what I learned about efficient office operations at the private practice, did some reading about queuing theory and succeeded in implementing a scheduling system that improved the experience for patients and increased the number of children for whom we cared by about 50%, with no increase in staff, while reducing the number of no-shows.
From this experience, I also learned that changing the system affected not only the patients but also the doctors caring for them. It was so much more satisfying to see patients in a system that ran efficiently, communicating to them that we respected their time.
My appreciation of the importance of the healthcare delivery system deepened when the NHSC transferred me to a storefront clinic, the South Central Community Health Center in downtown Los Angeles. By the time I left Rochester, I had realized that I needed to have more skills than I had learned in medical school if I was going to change systems of care. I wasn't hesitant to share my "big ideas" for better healthcare delivery with the partners of the Elmwood Group. One evening after work, one of the senior partners, Mike Pichichero, MD, put his arm on my shoulder and said, "Margolis, you better not become one of those academic types who studies why those of us in practice don't use evidence or don't do the right thing for our patients. You better figure out how to be useful." I will return to the theme of being useful later on.
In Los Angeles, I learned a lot about what could be accomplished with extremely limited resources. The clinic was supported by community philanthropy and by the medical staff's efforts to keep costs to the bare minimum. We were practicing in one of the most dangerous neighborhoods in the city and served mostly Central American immigrants who were ineligible for Medicaid because they had immigrated illegally. The cost of our services was $11 per visit, including medications, yet we were able to arrange specialty care for our patients by identifying sub-specialists who would see our patients for free. We also offered linkages with other needed community services for kids.
In summary, my experience in the NHSC gave me the truly unique opportunity to get to work in different settings and to see what various systems could accomplish. These indelible experiences allowed me to appreciate the importance of systems and processes. I learned by observation at the Elmwood Group that it was feasible to do excellent quality research in practice. I also learned that by staying focused on improving outcomes, I could bring systems into focus. In addition, I realized that paying attention to (and using) knowledge gained from variations across practices could be useful in system redesign.
About the Author(s)Dr. Margolis is Co-Director, Center for Health Care Quality and Professor, Department of Pediatrics, university of Cincinnati College of Medicine
AcknowledgmentFrom the chapter: "Learning Another Language" one of 16 essays in the book Lessons Learned in Changing Healthcare . . . and how we learned them. Edited by Paul Batalden. Published by Longwoods Publishing Corporation.
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