Uncovered in Egypt's tomb-laden Valley of the Kings and dating back to 1500 BC, the world's first known surgical text describes a process of care remarkably similar to the one which doctors follow today. It provides advice on examination, diagnosis, and treatment customized to the needs of the individual patient.
The big difference today, of course, is that knowledge about medical care has dramatically expanded and become increasingly specific. Another change, just as important, according to HBS professor Richard Bohmer, is that while a treatment outcome used to be based on an individual physician's performance, it now hinges on organizational performance. The shift from lone doctor to wide organization has critical implications for operations design, the structure of the medical industry, and practitioners'—as well as patients'—roles, tasks, and boundaries, he said.
Bohmer, who spoke on "Changing Models of Healthcare Delivery" at the 5th Annual Alumni Healthcare Conference on November 5, 2004, teaches the MBA course on managing healthcare technology and operations. He is also a physician trained in family medicine and public health. He introduced his talk by discussing the Egyptian find in order to illuminate how much has changed in healthcare and, to a degree, how much has not.
What hasn't changed: Physicians are still ethically bound to "treat all comers" who need medical care. And risk selection among patients is frowned upon from an ethical standpoint, said Bohmer. Despite all our medical wisdom, the outcome of treatment is still often uncertain, he said. In addition, new diseases such as AIDS, SARS, and avian flu continue to emerge, while obesity, menopause, and old age—which were once phenomena—have become medical problems, he said.
Change was slow in arriving. Only in the early nineteenth century, for instance, did doctors realize that dirt carried infections, and that these infections were transportable on hands. The unstructured problem-solving of learning about infection led to pattern recognition—"Dirt matters"—which led to rules application—"Wash your hands." The unstructured problem-solving, pattern recognition, and rules-application had an impact on the way medical decisions were made, he said.
Until the nineteenth century, a physician was more or less a solo pioneer. He was an experimenter, decision maker, and the person who carried out the decision, all rolled into one. In the twentieth century, roles changed and physicians were less likely to be experimenters, acting more as decision makers and clinical judges. Now in the twenty-first century, the doctor often has a new professional role as manager and system architect.
The patient side
The role of patients has been transformed as well. Not long ago, they were still relatively passive, ignorant of their condition, and dependent on the doctor's advice. But now they can choose self-testing for at least some conditions such as diabetes, high blood pressure, and pregnancy. A small but determined cadre, said Bohmer, are making rules-based decisions for themselves.
| There is a very important new assumption about how competent patients are. |
These days, even though the uncertainty surrounding many medical conditions has been reduced, the problem remains of how to reliably execute the rules. Diabetes is one of the few diseases that can be controlled fairly easily by rules-application, Bohmer said, using the example of a diabetic colleague who ran personal experiments on himself to learn the precise effects on his body of foods such as mangoes and bananas.
The unstructured problem-solving part of diagnosis now usually falls to specialists. Pattern recognition is the domain of primary practitioners. And rules-application can sometimes be handled by a nurse practitioner and a cooperative patient.
One organizational structure that has emerged is based on the "sort and reject" strategy of risk selection, said Bohmer. Certain hospitals specializing in cardiac or hernia care often do more sorting and rejecting of potential patients than we would like to believe, he continued.
"In order to develop an operational model where there's a very good fit between a homogeneous patient input and a highly specified production line, they sort and reject. They have solved the problem of whether to do custom or standard care by only doing standard," he said.
Tools of the trade
On the other side of the coin, a greater variety of products is emerging so that more patients can take more control over their own health. (Compliance remains a very important issue, Bohmer stressed.) Thanks to TV commercials, blues star B.B. King has popularized the OneTouch blood glucose monitor, so diabetics can monitor and manage their condition. The Health Hero Network, whose clients include the Veterans Administration and the Walter Reed Army Medical Center, has tools and programs for monitoring diabetes, asthma, post-acute care, and cardiovascular disease, among other conditions. The morning-after pill, which is used elsewhere in the world without a prescription but not yet in the U.S., could be used by women here without need of a doctor if not for a regulatory—not scientific—hurdle, said Bohmer. And psychiatric therapy is still full of variables and is not a candidate at the present time for patient self-diagnosis and care.
The development of programs and tools for patients to take more control of their health is based on "a very important new assumption about how competent patients are," said Bohmer.
"Not all patients are going to want it. Many patients are going to much prefer a rather more paternalistic relationship with their physicians, and that will be fine. [The preferences] will probably shake out by generation.
"My dad used to put on a jacket and tie to go see his primary care practitioner. … But there will be increasingly another group of patients who want to move to the other end of the spectrum in collaboration with businesses and role groups who are willing to support them," he said.
The increase in knowledge specificity, thanks to a dramatic increase in clinical studies over the past thirty years, he concluded, is "the engine moving decision-making capability and therefore decision rights to the patient." 