International Hospital Medicine

Saying “No” While Being NICE

A wise man once quipped that saying that we may need to ration healthcare is like saying that we may need to respect the laws of gravity. In other words, when societies have more healthcare needs and wants than resources (and all societies do), rationing is inevitable. The question of how to ration used to be the stuff of academic parlor discussions between health policy wonks and ethicists. But it now occupies center stage in the schoolyard brawl that passes for political discourse in today's America. Exhibit A, of course, was Sarah Palin's fear-mongering over “Death Panels.” Exhibit B: the Right's christening of Don Berwick as "Rationer-in-Chief" (and a communist, for good measure) because he had once expressed his admiration for the British National Health Service. At IHI last week, a newly unplugged Berwick -- fresh from his resignation as Medicare chief -- spoke passionately of solving our healthcare cost…

“I’m the Main Breadwinner”: The British Primary Care System and Its Lessons for America

I’ve heard a lot of shocking things since arriving in England five months ago on my sabbatical. But nothing has had me more gobsmacked than when, earlier this month, I was chatting with James Morrow, a Cambridge-area general practitioner. We were talking about physicians’ salaries in the UK and he casually mentioned that he was the primary breadwinner in his family. His wife, you see, is a surgeon. This more than any other factoid captures the Alice in Wonderland world of GPs here in England. Yes—and it’s a good thing you’re sitting down—the average GP makes about 20% more than the average subspecialist (though the specialists sometimes earn more through private practice—more on this in a later blog). This is important in and of itself, but the pay is also a metaphor for a well-considered decision by the National Health Service (NHS) nearly a decade ago to nurture a contented,…

Acute Physicians: Hospitalists Bounded by Time and Space

Besides studying patient safety and watching all five seasons of The Wire, my other major goal for my London sabbatical was to understand the way the Brits organize hospital care. Mirroring the U.S. hospitalist movement, a new field—called “acute medicine”— emerged about 15 years ago and became the country’s fastest growing specialty. But there is a key difference: acute physicians are hospitalists working inside a smaller box, the acute medical unit. While the young field has enjoyed some striking successes, I recently spoke at its national conference and challenged acute physicians to be a bit more ambitious—to put a little more of the “disruptive” in their disruptive innovation. To understand the different evolutionary paths of the U.S. and UK’s systems of hospital care, it’s important to understand the primordial seas from which hospitalists and acute physicians emerged. Whereas the U.S. hospitalist model has all-but-replaced a system in which the primary care…

Patient Safety in the US and UK, Part II: Top-Down vs. Bottom-Up

In my last post, I discussed the role of physicians in patient safety in the US and UK. Today, I’m going widen the lens to consider how the culture and structure of the two healthcare systems have influenced their safety efforts. What I’ve discovered since arriving in London in June has surprised me, and helped me understand what has and hasn’t worked in America. Before I arrived here, I assumed that the UK had a major advantage when it came to improving patient safety and quality. After all, a single-payer system means less chaos and fragmentation—one payer, one regulator; no muss, no fuss. But this can be more curse than blessing, because it creates a tendency to favor top-down solutions that—as we keep learning in patient safety—simply don’t work very well. To understand why, let’s start with a short riff on complexity, one of the hottest topics in healthcare policy.…

Patient Safety in the US and UK, Part I: The Doctors

A little more than a decade ago, the patient safety movement hit both the United States and the United Kingdom like twin avalanches. In both countries, high profile cases of medical mistakes led to growing anxiety, and early research outlined the vast scope of the problem and identified some solutions. All this was prelude to two key reports published in 2000 (the Institute of Medicine’s To Err is Human in the US, and An Organisation with a Memory in the UK), which blended data and angst to galvanize movements in both countries. When an avalanche strikes, its path is determined by the underlying terrain. So too have the structures and culture of the US and UK systems influenced their responses to the harrowing recognition that patients are often harmed while receiving healthcare. In this blog, I’ll highlight some of the key differences in the role of physicians—in particular, their engagement…