Here is the question: In a modern preventive and prospective health care system, supported by the relationship between the people and the people caring for the people, should the consumer help define health professionalism and continually assess health professionals performance as defined by this code?
In the previous four segments of this deep dive into what I term “Advanced Professionalism”, we’ve looked at the labels used to define “Professionalism”, questioned whether the health care system was determining who we were becoming, looked at the high minded vision embodied in the Tavistock Principles and wondered what had become of them, and explored whether thought leaders who support transformation of the system were having limited success due to “under-visioning”. In the last piece I offered three visions which I believed were “sufficiently powered” to support a full bodied transformation upon which modern “advanced professionalism” might be based. These included: pursuing health as a personalized, prospective strategic planning endeavor; centering healthy delivery systems around creation of healthy homes; and moving health delivery teams toward these homes rather then moving patients and families out of homes toward hospitals and health professionals’ offices. (1,2,3,4)
This week, we inject the consumers’ voice. As a proxy, I have chosen to review the classic 2003 FACCT (Foundation For Accountability) Report, “Innovators and Visionaries: Strategies for Creating a Person-centered Health System”.(5) FACTT was the brain child of David Lansky PhD, current President of the Pacific Business Group on Health. As their website states, “For more than twenty years, he has been a proponent of a more responsive health care system in which consumers are partners in their care and help shape the delivery of care.” (6) An expert in quality measures and information systems, Lansky was with the Jackson Hole Group in 1993 and 1994 (Clinton Health Care years), ran FACCT from 1995 to 2003, and merged it into the Markle Foundation ( an organization committed to leveraging the full benefit of modern health information technologies) in 2004. (7)
The “Innovators and Visionaries” report, constructed with inputs from a multi-sector expert panel (8), is another one of those “must reads” on the path to “advanced professionalism”. Here’s in part what they said now 7 years ago:
“We have built and enjoy a society that is rich in information, highly educated, democratic, and individualistic. In matters as mundane as driving their cars and as complex as managing their 401(k) and voting for national leaders, Americans can assimilate complex information, conduct themselves responsibly, and be sensitive to the common good.”
“Our health care system makes little use of these capabilities and performs poorly at addressing contemporary needs. Between one-third and one-half of all medical care is inappropriate or deviates from standards of best care. High numbers of patients and caregivers are not given the basic information needed to care for themselves and are too often excluded from decision-making. Too many people do not know what good care looks like, or how to seek it out. Providers are almost never rewarded for providing the best possible care. America needs a health care system that reflects the realities of the 21st century: a technologically enabled public, a growing aging and chronically ill population, an increasing evidence base of medical practice, and emerging information and biomedical technologies.”
“Such a transformation will occur only when we change the payment, culture and infrastructure of health care and fully engage Americans as patients, caregivers, consumers, and citizens. We call this future system person-centered. What is a person-centered health system? A person-centered health system has four dimensions:
1. Health: The system will help most people understand, be responsible for, and be able to take care of their own health to the maximum degree possible.
2. Health care: The system will make available the most effective professional and institutional resources to assist people when they can no longer manage their own health without that help. The system will embrace and promote the principles of ‘patient-centeredness’─self-care, personalization, transparency, redesign, quality, justice, and control.
3. Financing: Every individual and organization – from the patient to the medical school to Medicare – will accept responsibility to use expensive resources appropriately and efficiently.
4. Citizenship: Society will embrace an explicit consensus of our responsibilities to each other – and the limits of that responsibility.”
Here we see, clearly drawn, a separation that occurs naturally when human beings assess their needs in light of human potential. First, health is quite different from health care. Second resources are finite and require careful and expert application. And third responsibility demands careful definition and deliniation of the roles of individuals, families and communities, as well as the roles and responsibilities of the health professionals themselves.
Stated differently, it is foolish to define “professionalism” in the 21st century in an “us” versus “they” manner. It is after all “we”. Back in 1993, how did David Lansky and his experts characterize positive enablers of health and health care?
“To enable more consumers to understand and manage their own health.
• High levels of awareness, self-efficacy
• General use of health risk assessment personal plan continuous monitoring
• Professionals actively support health maintenance
• Coverage for self-management resources, non-visit care
• Financial incentives for maintaining wellness
• Rich, accessible, private personal health information environment
• General knowledge of relevant guidelines, safe medication practices, wise consumerism and system navigation”
“To enable more consumers to understand, affect, and participate in the care they receive from health professionals.
• Individual physician visit not the central mode for care
• Physician is information coach as well as technician
• Care provided by multi-disciplinary and community-based teams
• Providers support, encourage patient autonomy, system navigation, informed choice
• Professionals evaluated by outcomes, conformity to evidence-based practice
• Patients, professionals share access to biomedical knowledge base
• Medical education (GME, CME, nursing) patient-centered
• Quality performance information widely available, easily understood for all providers”
Completing the loop then, are there systematic proposals that have been tried that might embrace the enablers above?One approach tested at Duke was described by Ralph Snyderman in JAMA this week.(9) In the article he states, ” A proposal to do this is ‘prospective care’, a strategic approach that combines personalized health planning with integrated care systems to focus on individualized health promotion, disease prevention, monitoring and early intervention. Personalized health planning has the potential to effectively engage individuals with an aligned delivery system and serve as a foundation for payment models for valued outcomes.”
One of those valued outcomes is “professionalism”.
For Health Commentary, I’m Mike Magee.
1. Magee M. Advanced Professionalism. Part I: Desirable Attributes in Health Care Professionals http://www.healthcommentary.org/?page_id=1617
2. Magee M. Advanced Professionalism. Part II: “Advanced Professionalism”: A View Standing On Others’ Shoulders. http://www.healthcommentary.org/?page_id=1694
3. Magee M. Advanced Professionalism. Part III: What ever happened to the Tavistock Principles and What is the consumers’ role in defining Professionalism? http://www.healthcommentary.org/?page_id=1798
4. Magee M. Advanced Professionalism. Part IV: Under-Visioning Professionalism: Deming, Berwick, & Sensemaking. http://www.healthcommentary.org/?page_id=1867
5. 2003 FACCT (Foundation For Accountability) Report, “Innovators and Visionaries: Strategies for Creating a Person-centered Health System”. http://www.markle.org/resources/facct/doclibFiles/documentFile_599.pdf
6. David Lansky Biography. http://www.pbgh.org/about_pbgh/staff.asp#DavidLansky
8. “Innovators and Visionaries” Expert Panel.http://www.healthcommentary.org/?page_id=1926
9. Ralph Snyderman, MD; Michaela A. Dinan, BS. Improving health by taking it personally. JAMA. 2010;303(4):363-364. http://jama.ama-assn.org/cgi/content/extract/303/4/363?home=