Greed should not be a factor in patient care, and yet more and more it seems to be. Dr. Donald Berwick has a wonderful article titled Salve Lucrum in JAMA, and I highly recommend it. He touches on how his father inspired and inspires him, the importance of community and connection, and the small steps we can take to fight greed. Dr. Donald M. Berwick, MD, MPP, FRCP, is President Emeritus and Senior Fellow at the Institute for Healthcare Improvement. He is former Administrator of the Centers for Medicare & Medicaid Services. Trained as a pediatrician by background, he has taught at Harvard Medical School and Harvard School of Public Health, and he has served on the staffs of Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital. He was Vice Chair of the US Preventive Services Task Force, the first "independent member" of the American Hospital Association Board of Trustees, and Chair of the National Advisory Council of the Agency for Healthcare Research and Quality, and the Institute of Medicine. Recognized as a leading authority on health care quality and improvement, Dr. Berwick has received numerous awards for his contributions, including from the British National Health Service in 2005, when he was appointed "Honorary Knight Commander of the British Empire" by Her Majesty, Queen Elizabeth II. Dr. Berwick is the author or co-author of over 160 scientific articles and six books. He currently serves as lecturer in the Department of Health Care Policy at Harvard Medical School. He has a new podcast in spring, 2023 called Turn on the Lights.
Greed should not be a factor in patient care, and yet more and more it seems to be. Dr. Donald Berwick has a wonderful article titled Salve Lucrum in JAMA, and I highly recommend it. He touches on how his father inspired and inspires him, the importance of community and connection, and the small steps we can take to fight greed. Dr. Donald M. Berwick, MD, MPP, FRCP, is President Emeritus and Senior Fellow at the Institute for Healthcare Improvement. He is former Administrator of the Centers for Medicare & Medicaid Services. Trained as a pediatrician by background, he has taught at Harvard Medical School and Harvard School of Public Health, and he has served on the staffs of Boston's Children's Hospital Medical Center, Massachusetts General Hospital, and the Brigham and Women's Hospital. He was Vice Chair of the US Preventive Services Task Force, the first "independent member" of the American Hospital Association Board of Trustees, and Chair of the National Advisory Council of the Agency for Healthcare Research and Quality, and the Institute of Medicine. Recognized as a leading authority on health care quality and improvement, Dr. Berwick has received numerous awards for his contributions, including from the British National Health Service in 2005, when he was appointed "Honorary Knight Commander of the British Empire" by Her Majesty, Queen Elizabeth II. Dr. Berwick is the author or co-author of over 160 scientific articles and six books. He currently serves as lecturer in the Department of Health Care Policy at Harvard Medical School. He has a new podcast in spring, 2023 called Turn on the Lights.
[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I have the great pleasure of speaking with Dr. Donald Berwick. Dr. Donald Berwick is President Emeritus and Senior Fellow at the Institute for Healthcare Improvement. He is former Administrator of the Centers for Medicare and Medicaid Services. Trained as a pediatrician by background, he has taught at Harvard Medical School and Harvard School of Public Health, and he has served on the staffs of Boston's Children's Hospital Medical Center as well as Mass General Hospital and the Brigham and Women's Hospital. He was Vice Chair of the US Preventive Services Task Force, the first independent member of the American Hospital Association Board of Trustees, and Chair of the National Advisory Council of the Agency for Healthcare Research and Quality as well as the Institute of Medicine. Recognized as a leading authority on healthcare quality and improvement, Dr. Berwick has received numerous awards for his contributions, including from the British National Health Service in 2005, when he was appointed Honorary Knight Commander of the British Empire by Her Majesty Queen Elizabeth II. Dr. Berwick is the author or co-author of over 160 scientific articles and six books. He currently serves as Lecturer in the Department of Healthcare Policy at Harvard Medical School. He has a recent viewpoint in JAMA, and I'll put a link to that in the show notes, on the risks of pursuing profit in healthcare. That was one of the main reasons asked if he would be willing to be on. So, welcome to Dr. Berwick.
[00:01:36] Donald Berwick: Thanks, Christine. I'm delighted to be with you.
[00:01:37] Christine Ko: Would you first share a personal anecdote about yourself since you seem larger than life with that bio?
[00:01:44] Donald Berwick: I'll share from my childhood, my experience growing up in a small town in Connecticut where my father was a general practitioner of the old style, made house calls, went to the hospital every day, delivered babies, was a very valued and honored member of his community. And that's always stuck with me as the image of being a physician, kind of embedded in a community, totally involved with the wellbeing of the people there. And obviously he made an income, but I saw him do a tremendous number of generous things. Just making sure that people got the care they needed and that image of public service, I guess it is, is just embedded in my mind as to the core of what the nature of healthcare ought to be.
[00:02:28] Christine Ko: I like that. Ever since I've practiced though, and there are no doctors in my family when I was growing up, so I didn't have that kind of model ever in front of me. And I feel like really the way I practice, I'm definitely not in the community at all.
[00:02:43] Donald Berwick: How do you feel? Do you feel isolated from the patients?
[00:02:45] Christine Ko: I used to more, for sure. I think that, like, part of being in a community is about the emotion that I have or the patient has because you see someone give birth and the joy of that and you see someone pass away and the grief of that. Maybe because I'm Korean American, and my parents immigrated here from South Korea, we never talked about, how are you feeling today? When my daughter was in kindergarten, her school is about incorporating social and emotional learning, which I didn't even know was a concept. I never got that in medical school or college or just any of the large amounts of training that all doctors get. Research suggests for everyone, the emotional piece overlays and underlies really everything. So, if I don't at least think about the emotional aspects that are in a patient encounter, it is really not gonna be as good an interaction for the patient, or for me, as it could be. I think the joy of medicine is actually about being a part of that patient's life, at least in the room.
[00:03:55] Donald Berwick: I know, and I think you know, that you never learn without making errors. The same is true in our work in healthcare. If we can't tolerate or are ashamed of being open and transparent when things aren't going well, then learning gets very hard. How can we develop a culture in healthcare in which we're constantly looking for the lessons we can learn and sharing of them with each other. I think shame keeps us from turning on the lights on exploring what happens, and how we can learn from each other, connecting things up. When you're connected, the science, understanding what you can, reaching for knowledge, trying stuff... it's all connected, isn't it? Whereas when we're staring at the computer screen as doctors or getting through a seven-minute encounter, it's so easy to become disconnected. [Yes.] Because it could feel overwhelming to try to really tune into what matters to the patient, and who is this person really?
[00:04:54] My own view is that a lot of the economics of healthcare now, as we look at payment systems and productivity requirements, might be moving in the wrong direction, making it harder and harder for clinicians of any type to forge the connections that you feel when you're trying to help.
[00:05:09] Christine Ko: Absolutely. That's why I really liked your article about focusing on profits. The vast majority of doctors don't actually come into medicine for profit at all. And then as you practice, it's about profit; it's about how much profit am I making for the system? Actually, unfortunately. Can you talk about that?
[00:05:33] Donald Berwick: Yeah. It has to do with who and what we're accountable for. My father made profit, it was called his income, and he charged patients and got paid by them and insurers, but I don't think it ran the show for him. We were in a small, rural town and sometimes people were very poor, and they would pay him, if at all, with chickens or eggs, or maybe not at all. But he still saw them, and I never once heard him complain about the payment system. I'm sure he wished that he could get more, but that wasn't driving him. [Yeah.] He was not a saint. He was a good person. And, nowadays what concerns me is that the way healthcare is headed with so much invested capital in it, with profiteering going on by almost anyone, drug companies, physician groups, insurers, hospitals; who are just focusing on getting revenue. It's alienating. It disconnects us, and I hear it from doctors. So, the article on greed that you're talking about that I published in JAMA a couple months ago; I've never had anything like the outpouring of correspondence that I'm getting from doctors and nurses and even managers who are writing to me saying, man, you've got it. This is not why I went into medicine. There have been over 125,000 downloads of that article, which is still up, free online. People can read it. So, it tapped a nerve about the relationship between one's purpose as a clinician, or any role in healthcare on the one hand, and this dominance of money. [Yeah.] And profit in the system. And I call it greed because it does sometimes become greed. It's, oh, gimme more and more. I don't know how to reconnect things, Christine. I don't know. I think that most people, like you, want to do the job completely. They really want to help people, and they don't want to be working under circumstances which make it hard to focus on job one, which is the patient. It's largely political, because as profit and acquisition have taken over in healthcare, with it comes lobbying power. The guilds and the large corporations become very powerful in their voice in Congress and in State Houses. And so there's a vicious cycle here, which is the more greed concentrates wealth, the more wealth concentrates political power. And the more political power gets concentrated, the harder it is to reign in greed, and that's the cycle.
[00:07:51] I think the kind of good heart you obviously have and your sense of wanting to connect to patients may be the resource that we could draw on to begin to reverse that cycle. But so far, we haven't.
[00:08:01] Christine Ko: Yeah. I know there's no immediate, easy solution, but do you think there are small steps that you try to take? Are there things that you try to do or you tell other people they might be able to do?
[00:08:14] Donald Berwick: Yeah, speaking up is what I'm trying to do. I hope people will read the article you're referring to. Make it available to people listening to you. We need to talk about this. We need to talk about greed and profiteering and money dominance in medicine, and the right people to encourage that conversation include clinicians, doctors, nurses, pharmacists, who ought to be fed up with this and ought to say so. Because nothing short of some kind of political mobilization or movement is gonna have the power to stop this. One of my recent areas of inquiry has been in terms of Medicare Advantage, which is the private side of Medicare, where about half of Medicare beneficiaries now enroll in health plans that are private. Those health plans are profiteering. They're playing games with pricing. They're playing games with diagnosis. They are making enormous profits, absolutely phenomenal profits, right off the backs of the government and taxpayers and Medicare beneficiaries. And it is striking to me how much control they have over the messaging.
[00:09:13] Do you know there was a Super Bowl ad sponsored by the Medicare Advantage industry, the health plans? [Wow.] For three and a half million dollars. They bought airtime at the Super Bowl to support Medicare advantage politically. Those are deep pockets and very strong invested interests. And those of us who care about preserving public financing of healthcare, universal access, proper stewardship of funding.... we don't have a budget of three and a half million dollars to take an ad out. That's why some form of a mobilization is the best I could do right now. Write to your representatives and Congress people. Speak to your patients and others, and say we've got to stop the greed.
[00:09:54] Christine Ko: Good advice. You touch on moral injury, demoralization, leading to disengagement. Do you have thoughts on how emotional intelligence or metacognition, thinking about our thinking, thinking about how we're feeling, can combat those things?
[00:10:12] Donald Berwick: Sure. A lot of doctors writing to me, and nurses, feel trapped. Moral injury is coming from them being forced by the environment, by the payment system, or the surveillance they're subject to, to engage in behaviors that are not healing behaviors. To be forced to rush through patient encounters. To focus on volume and pricing. It drives them nuts. They hate it. They just hate it. But they feel helpless to change it. So I think that becoming aware of that cognitively to understand that the way you're feeling is being enforced on you by an environment that is not aligned with your purposes in life. That begins the process.
[00:10:52] The second is to find your friends. I think there's a lot of people that are feeling this way, and it gets very lonely to feel that I can't do the work I want to do. When others feel that and you're together, something positive begins to build that, We're in this together. We can change.
[00:11:07] I may not be able to make the change, but together we can.
[00:11:10] And I think that joining up and having these conversations, it's potentially healing. And then I think in whatever platform of influence you have, whether it's in the medical staff of your hospital or your conversations with executives or however you can speak up about it and say, this has gotta change.
[00:11:29] What creates demoralization is a lack of a sense of agency. It's a, I'm in trouble and I can't do anything about it. [Yeah.] We need to change that thinking and say, we must do something about it. [Yeah.] I know that's kind of a vague idea about how to make changes, but physicians have a lot more power than they think they do, especially if we get together and defend the patient, which is really what this is all about.
[00:11:51] Christine Ko: Yeah, that's true. I think this sort of, maybe, siloing off of people, coming back to what you're saying, lack of connection, sort of reinforces the problem because you do feel alone, and you think you're the only one. Sometimes, for example, in my department, you're made to feel like you're not measuring up, and that's why I might be having a problem. Like, I'm not generating enough RVUs or something, and it's me, like I'm just [yeah], like a bad apple. And so then I think that's where the shame comes in again, because if I feel ashamed, I don't wanna tell anyone, like, oh, I'm the bad apple. At the same time you're working so hard, and answering all these electronic medical record messages for which, there's no RVU counts for that. But it's like important stuff, and yet they're telling you have to do it....
[00:12:45] Donald Berwick: There is shame again, isn't it? I guess the only message I've got for you and your listeners is, you are not alone. You are not alone. That you're feeling what others are feeling. And recognizing that we need to get together about this instead of being trapped in our personal silo, that's crucial. We can't get this change done, in isolation, alone. To the doctors and nurses who are feeling this, I'm saying, you are not wrong. The environment is wrong. And if the message is telling you that you're letting them down, it's the other way around. We've built a healthcare system, largely driven by profit and finance, which is letting you down, letting the patient down, and it's time to change that. It's a hard, it's a hard message. But I know that I can feel it out there that people are saying this isn't gonna work, and the answer is, it's not gonna work, and we have to change it. The root problem here is the dominance of the profit motive and opening the door to profiteering and investor capital and thinking about money instead of patients.
[00:13:42] There's a paper by two Harvard Medical students of mine in the Journal of General Internal Medicine recently, in which they just looked at the board of trustees membership in 15 large academic medical centers. And only 14.7% of the members of boards were people who had anything, any experience at all with patient care. Doctors, nurses. [Wow.] Clinicians. By far the largest representation in governance are from the investor community. Real estate, real estate executives, financiers; and they may be good people, but they're missing the point. This does to me, in part, go back to governance and what the real job of governance is. So, we got some problems here, Christine. We gotta dig out of them. We need to have gumption, with respect to correcting the system that's got us trapped right now.
[00:14:31] Christine Ko: Yeah. That's really important stuff you just said. Do you have any final thoughts?
[00:14:37] Donald Berwick: Only to thank you for your good work, the depth of your thinking, your willingness to have these conversations out loud. That's what we need to do. I should say, I'm starting a podcast with my colleague, Kedar Mate. Kedar is the CEO of the Institute for Healthcare Improvement ,and Kedar and I have been recording what we'll soon launch. A podcast called, Turn on the Lights. It should be out in the next several weeks. We're trying to have guests and conversations that help non-professionals in healthcare, people who are just out there in the public, to understand what's going on inside healthcare, because it gets very opaque, very complex, and we want to demystify it because a mobilized population is in the end going to be able to change what you and I are talking about.
[00:15:18] So, let me just encourage your listeners to seek out, Turn on the Lights, probably available in about three or four weeks.
[00:15:24] Christine Ko: I'll have to look for it. Yeah, I'll put that in the show notes, too. Thank you so much for spending time with me.
[00:15:30] Donald Berwick: It's a pleasure, and thanks for all your good work, Christine.