Dr. Peter J. Weiss

Michelle Obama

“Barack, like any leader, is human. And, you know, our chal­lenge in this coun­try isn’t find­ing the next per­son who’s gonna deliver us from our own evil. Because our chal­lenges are us. The chal­lenge that this coun­try faces is how are we as indi­vid­u­als in this soci­ety gonna change? What are we gonna do dif­fer­ently?”

– Michelle Obama, Inter­viewed by Katie Couric, CBS Evening News,  2/15/08

Mrs. Obama made an astute obser­va­tion and asked the right ques­tion. There is no “one deliv­erer” from our prob­lems. We will have to save our­selves — from our­selves.  Then she asked essen­tially, “What is each of us going to do?”

So, what am I going to do dif­fer­ently?  What are you going to do dif­fer­ently?  What are we physi­cian lead­ers going to do about our col­laps­ing health­care sys­tem? I wouldn’t hold out hope that our national polit­i­cal lead­er­ship will “fix” the sys­tem any­time soon.

Cri­sis Com­ing For Years

For­mally, our coun­try debated a solu­tion to the health­care predica­ment for over a year.  Less for­mally, aca­d­e­mics, pol­icy mak­ers, and those of us pay­ing atten­tion have seen the cri­sis com­ing for years.

At this point, we have a new law that adds com­plex­ity to an already too-complex sys­tem with­out clearly address­ing the core issues dri­ving cost increases. Our dys­func­tional leg­isla­tive bod­ies did not rise to the occa­sion.

Physi­cian lead­ers under­stand the com­plex­ity of our sys­tem, hav­ing expe­ri­enced it first hand.  Me too.

Until recently, I was CEO of a 60,000-member health plan.  Under my tenure we under­took a 2-year, $10 mil­lion infor­ma­tion sys­tems con­ver­sion.  The project wasn’t designed to give us a major com­pet­i­tive advan­tage, but rather just to meet ongo­ing busi­ness require­ments.  At some point in the labyrinthine project meet­ings I began to think, something’s wrong here.  Does health­care really have to be this com­pli­cated?  This just isn’t right.

More thoughts fol­lowed:  Are elec­tronic med­ical records really going to cause a major improve­ment in qual­ity and out­comes?  Are they worth the cost?  Where is this whole sys­tem headed?  How exactly is ICD-10 going to help?  Will any action that increases com­plex­ity be help­ful?  I think not.

Mean­while, run­ning on a par­al­lel track, a sec­ond train of thought about the nature of health­care ser­vices was also dis­turb­ing me:  Do we really need more doc­tors and more care?  Up to 70 per­cent of health care in the United States is ren­dered for poten­tially pre­ventable con­di­tions.

About a third of all care is esti­mated to be use­less or harm­ful.  Taken together these fig­ures sug­gest that almost 80 per­cent of health care would not be nec­es­sary if we could change how we live and do only what is needed.

“Turf Pro­tec­tion”

Another issue weigh­ing on me was spe­cialty pro­lif­er­a­tion and the asso­ci­ated “turf pro­tec­tion.”  Just how much spe­cialty care can be ren­dered at lower cost by pri­mary care doc­tors?  And how much pri­mary care can be ren­dered at lower cost by nurse prac­ti­tion­ers and physi­cian assis­tants?  Prob­a­bly most.

Are elec­tronic med­ical records really going to cause a major improve­ment in qual­ity and out­comes?

Even­tu­ally the two streams of thought merged and the pres­sure to take action mounted.  What am I doing? Why am I here? Every day I get up, come to the office and help to build a more com­pli­cated health­care sys­tem to help deliver care that peo­ple shouldn’t need or want.  I am mak­ing things worse!  I can’t keep doing this.  It was the begin­ning of the end for my career in tra­di­tional health­care.

As you might expect some nat­ural follow-up ques­tions occurred:  Now what?  What do peo­ple need? What does the coun­try need? How can I help?  What exactly should I be doing?

Upon con­sid­er­able reflec­tion, I answered my ques­tions. I decided that:

• Peo­ple need more health and less care.
• Our coun­try needs a major pub­lic health approach to health and well­ness and a much sim­pler approach to “tra­di­tional health­care.”
• I prob­a­bly can’t mean­ing­fully influ­ence Con­gress or Pres­i­dent Obama, but I can spread the mes­sage and I can help indi­vid­u­als.
• I will be a “Well­ness Evan­ge­list.”

Let’s face it, more spend­ing and more com­plex­ity is not the answer for the United States.  Why do we keep try­ing the same old thing?  When you’re in a hole, stop dig­ging.  Each year Amer­ica spends increas­ing amounts on health­care and we develop new more advanced treat­ments, but our over­all health con­tin­ues to dete­ri­o­rate.

Lifestyle Is the Prob­lem

Our col­lec­tive lifestyle is the prob­lem.  In gen­eral, our diets are lousy.  We don’t sleep.  Exhaus­tion has replaced exer­cise. Drugs and alco­hol are con­ve­nient escapes.  We accept high lev­els of phys­i­cal and emo­tional stress as a part of life, and we turn to med­i­cine to solve our lifestyle-created prob­lems.

Some would say we are mak­ing bad choices.  Per­haps they’re right, but are we really “choos­ing” or is our envi­ron­ment fos­ter­ing unhealthy lifestyles?  Why is the epi­demic of obe­sity hap­pen­ing now?  What’s dif­fer­ent about now as com­pared with two decades ago?  Did our col­lec­tive Amer­i­can char­ac­ter change?  Did we choose this?

Truth is, our cul­ture and envi­ron­ment shape our lifestyles in ways we barely notice. We Amer­i­cans come from tough stock but we have slipped into a new and unhealthy “nor­mal” lifestyle.

Large por­tions of unhealthy food sur­round us and pro­vide a nearly irre­sistible oppor­tu­nity to overeat.

Large por­tions of unhealthy food sur­round us and pro­vide a nearly irre­sistible oppor­tu­nity to overeat.  We have designed man­ual labor out of most work­places.  Elec­tronic pas­times have sur­passed active recre­ational pur­suits.  You must live an almost counter-cultural lifestyle to be healthy in Amer­ica today.

The argu­ment to take no social action because these issues are “per­sonal choices” is irre­spon­si­ble.  When did we as indi­vid­u­als or as a soci­ety con­sciously choose to get ill?  Did any of your patients, friends or neigh­bors wake up one morn­ing and say to them­selves, “Today I’ll start overeat­ing to become obese.  Maybe if I work at it, I can have dia­betes some­day!” Of course not.

It’s time for an aggres­sive pub­lic health cam­paign geared towards gen­er­at­ing health­ier lifestyles.  The pub­lic health cam­paign to reduce cig­a­rette smok­ing has worked won­ders.  Now let’s attack obe­sity, dia­betes, hyper­ten­sion and other pre­ventable lifestyle ill­nesses with the same inten­sity.

As physi­cian lead­ers you know this envi­ron­men­tal approach is needed.  You have learned it on the job.  After all, what is the first tenet of qual­ity improve­ment?  That it’s about the sys­tem not about the peo­ple — that is, seek to change the sys­tem to pro­duce the right behav­iors and out­comes.

Ask­ing each sur­geon to be “extra care­ful” or “make dou­ble sure” he is per­form­ing the right pro­ce­dure at the right site is not as effec­tive as stan­dard­iz­ing informed con­sent, site mark­ing and pre­op­er­a­tive time out pro­ce­dures.  Sim­i­larly, a plan to edu­cate indi­vid­u­als about mak­ing “bet­ter choices” will not be nearly so effec­tive as alter­ing our envi­ron­ment.

Things Will Likely Get Worse Before They Get Bet­ter

How­ever, I am a real­ist.  Tax­ing high caloric den­sity foods, reduc­ing por­tion sizes, lim­it­ing food avail­abil­ity, con­trol­ling adver­tis­ing and fur­ther reg­u­lat­ing the nutri­tional con­tent of foods won’t hap­pen overnight.

It will be very con­tro­ver­sial by nature, and pow­er­ful polit­i­cal forces will oppose even rea­son­able pub­lic health mea­sures to com­bat our obe­sity epi­demic.  As with the Con­gres­sional “reform” of health­care, things will likely have to get worse before they can get bet­ter.

Of course we will still need a robust health­care sys­tem even after our pub­lic health cam­paign, and our health­care sys­tem has got to be sim­pli­fied.  Do you think that “if we just got the CPT codes and RBRVS right” the sys­tem would work prop­erly?  Do you think ICD-10 will help any­thing about health­care in Amer­ica?  Really?

We need a par­a­digm shift.  We must sim­plify. Com­plex­ity is the prob­lem not the answer.

Insur­ance is nec­es­sary, but our cur­rent third party payer sys­tem is part of the prob­lem.  The intri­cate cod­ing sys­tem only exists because of third party pay­ers, and the “moral haz­ard” issue of today’s third party sys­tem is real. Mod­ern health insur­ance prod­ucts func­tion more as pre-paid med­ical care rather than true insur­ance, dis­tort­ing incen­tives and dri­ving com­plex­ity.

Can you imag­ine a sys­tem where indi­vid­u­als were largely respon­si­ble for their own med­ical costs (backed up by a cat­a­strophic pro­tec­tion pol­icy) and all providers charged by the hour or the visit?  I can.  How much sim­pler would that sys­tem be? Does this sound too rad­i­cal?  Per­haps it is, but sim­pler must be our direc­tion.

For most peo­ple, par­a­digm shifts or new awak­en­ings hap­pen infre­quently and can be very hard to make.  Mine was some­what painful.  Will we in the United States col­lec­tively make the shift I pro­pose?  Maybe.  Peo­ple are start­ing to become inter­ested in new ideas, even rad­i­cal ones.  But I’m not count­ing on it. Until we do, I’ve decided to focus my career on help­ing indi­vid­u­als get well.

Let’s get spe­cific.  What exactly do indi­vid­ual Amer­i­cans need in order to become healthy in our envi­ron­ment, the envi­ron­ment that has led to an epi­demic of obe­sity, inac­tiv­ity and lifestyle dis­eases?

Here’s what I think:

They need to learn that being unhealthy is not all their fault, but that address­ing it is their respon­si­bil­ity.  And they need to be invited to accept that responsibility. They need inspi­ra­tion, encour­age­ment, and new ideas about liv­ing dif­fer­ently.

They don’t need blame, shame or criticism. They don’t need to be told how to live.  They need help in cre­at­ing their own new lifestyle. In short, they need empow­er­ment.

Empow­er­ing Indi­vid­u­als

As a well­ness evan­ge­list my new per­sonal mis­sion is to empower indi­vid­u­als to take charge of their life and their health in order to achieve health and well­be­ing.

Per­haps I will rejoin the tra­di­tional health­care sys­tem again some­day, but I doubt it.   How­ever, I still con­sider myself a physi­cian leader and am proud to be part of our fel­low­ship.  Most of you, like me, prob­a­bly didn’t go to med­ical school with the inten­tion of becom­ing a leader of the health­care sys­tem, but here you are.

Fur­ther­more, as doc­tors, you are used to par­a­digm shifts in med­i­cine.  How many fun­da­men­tal changes have you seen in med­i­cine over your career?  We are con­stantly called to reeval­u­ate what we “know.”  When I went to med­ical school, stress and excess stom­ach acid caused ulcers.  Now we know of Heli­cobac­ter pylori and the infec­tious nature of gas­tric and intesti­nal ulcers. That was a par­a­digm shift!

I invite you to lead in a new direc­tion.  What do you think about our health­care sys­tem and where we’re headed?  Do you go to your office every day, like I did, know­ing that you’re a major par­tic­i­pant in a fun­da­men­tally bro­ken sys­tem?  It’s okay to admit it.  I am not going to tell you to quit your job, write a book and become a well­ness evan­ge­list.  But I am going to ask you to take action.

Ask your­self the same ques­tions I asked myself:

• What do peo­ple need?
• What does the coun­try need?
• How can I help?
• What exactly should I be doing?

Be seri­ous and strug­gle with these tough ques­tions.  Be will­ing to con­sider new and rad­i­cal ideas.  Our old ones aren’t work­ing.  Come up with your own answers — seri­ous answers.  Then take action!

I urge you to sup­port a pub­lic health approach, and to help spread the word that more health­care and more com­plex­ity are not the answers.  But what­ever your views, please speak out on the health and health­care issues plagu­ing our land.

There are few lead­ers as uniquely qual­i­fied as physi­cians to make a dif­fer­ence in this debate.  And if you decide to be a well­ness evan­ge­list, give me a call!