It's About Time

Chances are, the sun isn't directly overhead for you when it is for me.  The sun probably rises and sets at different times for you than for me.  That's why for most of human existence time was a local matter.

Nowadays, of course, we have Greenwich Mean Time, we have time zones that span the globe, and we have clocks so accurate that satellites have to take into account relativistic time-dilation effects.  You not only can know exactly what time it is where you are, but also at any other point in the world.

Technology made the change possible, and necessary. 

Health care should learn from this.

It used to be that local time was good enough.  You lived most or all of your life in a geographically constrained area, so the village clock served your purposes.  If you traveled, you simply had to adjust to local time.  You probably didn't even think twice about it.

It was the railroads that made this impractical.  People wanted to know when trains would arrive, and when they'd leave.  More importantly, if they were't coordinated, trains traveling in different directions might -- and did -- run into each other.

The railroads made standard time necessary.  The telegraph made it possible. 

Telegraphs allowed people in two locations to agree on what time it was "now."  You could send a virtually instantaneous signal saying, "it's midnight here Greenwich."  We could set up standard time zones.

Surprisingly, it took much decades for people to embrace this.  In the U.S., for example, the railroads moved to standard time in 1883, but the U.S. didn't officially adopted it until 1918.   England, which started the whole idea, had converted by 1880. 

We treat health care much like we used to treat time. 

Dartmouth Atlas, "What Kind of Physician Will You Be?"

That is, it is largely local.  How it is practiced in one community may not be how it is practiced in the next community, or even the next hospital or physician practice within a community.  We know this, and have known it since at least the early 1970's, due to the work of John Wennberg at Dartmouth. 

The care you get will depend on, of course, what is wrong with you, but also on which physician you see.  And where they went to medical school, where they did their residency, what hospital they practice in, who they practice with, what studies they have seen/remembered.  And how they are paid. 

A recent survey found that most clinicians agreed that practice variation should be reduced, but were less confident that it would be.  They thought that some situational variation was justified, but that as much as one-third was unwarranted. 
 
Very few dispute that there is significant variation in care, or that it is probably bigger than it should be.  We have lots of practice guidelines and protocols that are aimed at reducing variation.  But there's not much evidence that it is getting any less. 

In fact, some argue that it might be getting worse.  In Health Catalyst, Dr. John Haughorn cited four reasons for this:

1. The healthcare environment is increasingly complex;
2. There is exponentially increasing medical knowledge;
3. Despite #2, there is still a lack of valid clinical knowledge; 
4. There is too much reliance on subjective judgement by clinicians.  

We accept these variations because, well, that's how it has always been.  We accept them because we think our personal situation is unique.  We accept them because we trust our local experts.   

We accept them for all the same reasons we used to accept that time should be local. 

Technology has made it both necessary and possible that we move away from this attitude.

It is necessary because the scope of the problem is clear.  As Propublica put it in a recent expose of unnecessary procedures: "Wasted spending isn’t hard to find once researchers — and reporters — look for it."  All that unnecessary care is bad for our pocketbooks -- and bad for our health. 

Almost twenty years ago the Institute of Medicine estimated as many as 98,000 hospital deaths annually due to medical errors.   More recently, medical errors have been estimated to be the third leading cause of death in the U.S. 

Another study found that 8.9% of U.S. surgeons believed they've made a major medical error within the last 3 months, and 1.5% believe it resulted in the patient's death.   Again, that's just within the last 3 months.

Yes, moving away from "local" health care is necessary.

The good news is that it is possible.  We have the technology to consult with physicians who don't happen to be local, such as through telemedicine.  And not just consult; we're even getting closer to telesurgery.  It is possible to get the "best" doctor for our needs, not just the closest.

We have more data than ever about us and our health.  We have artificial intelligence that can analyze all that data plus all those medical studies that no human can possibly keep up with.  It is possible to come up with the "right" recommendations for us.   

We have to stop thinking of health care as local.  The information it is based on is not.  The people who are best able to apply that information to our situation may not be.

If I get a driver's license, I don't have to get another one when I drive to another state.  If I get on a plane, the pilot doesn't have to have a pilot's license from each state he/she lands in, or flies over.  We've recognized that that kind of local control doesn't make sense.

But if I want to use a doctor who is in a different state (or country), that doctor needs a license from my state.   That doctor may be the best trained person in the world for my needs, with empirical data to prove it, but it doesn't matter.  Someday, the best doctor for us may not even always be a person.

We've always justified such licensing by states wanting to ensure the safety of their citizens, but drivers and pilots can put those citizens at risk too.  It's not really about risk; it's more about controlling competition.  With that attitude we'd never had had Walmart, or Amazon, but in health care we accept it.

There is irrefutable evidence that local health care is rarely what is going to be best.  It might not be bad care, but most likely it's only going to be average. 

Maybe we're willing to settle for that.  I'm not.

Time for a change.