56. Medical education will recognize that because only 10–20% of health outcomes are driven by clinical care, physicians must also be stewards of community transformation. Physicians are in the best position to be good partners within a multi-disciplinary alliance enabling community transformation.

Dr. Clay Johnston, Dean, Dell Medical School at The University of Texas at Austin

This is part of a series of essays on the Health Rosetta’s Principles.

If we really want to meet society’s goals for health and healthcare, medical schools are going to need to step up and break the traditions that define them today. Academic medical centers have been optimized to succeed in a fee-for-service system that is focused on illness—the more severe the better—from a reimbursement standpoint. But society wants health, and society should be willing to pay for it, because health is a lot cheaper than illness.

Medical schools have been built over many years around the patient-doctor couplet. The doctor is devoted to the individual patient, guiding him or her through illness by providing comfort, palliation and treatment. Drugs and procedures are the main tools of the traditional physician, directed by the clinical history, the physical exam and, sometimes, extra tests.

In this model, the value of the physician seems greater if the immediate need is greater. Time spent advising someone to stop smoking just does not intuitively seem as valuable as time overseeing a code blue. Furthermore, more complicated interventions, such as surgeries, seem more valuable than vaccinations. So it really shouldn’t be a surprise that the healthcare system reimburses much more for urgent interventions than for prevention and counseling. Centers that concentrate on complex and urgent interventions—tertiary care centers—have tended to be well reimbursed for their efforts and generally make up the most profitable segment of the healthcare system.

Medical schools have always been referral centers for more complex cases, and faculty have tended to be at the forefront of innovation. This aggregation of expertise has made academic medical centers logical places to send patients who are difficult to diagnose or treat, establishing their role as tertiary care centers. The highest level trauma centers, most sophisticated cancer centers, and best performing heart centers have often been associated with medical schools.

Academic medical centers have prospered by focusing on tertiary care. In the fee-for-service system that dominates healthcare today, tertiary care is particularly lucrative. Revenues from clinical care have helped to support the research and teaching missions of academic medicine. As public support for education and research has decreased, medical schools have become more dependent on revenue from tertiary care to cross-fund the other missions. Thus, medical schools are highly dependent on stable profits from fee-for-service medicine—treating the sickest of the sick—for their entire enterprise.

This emphasis on tertiary care runs counter to society’s needs. People want to be healthy. They don’t want to have to go to the hospital or see a doctor in a clinic; they want to be pain and problem free, fully independent, highly mobile, and completely engaged. No one wants to be a patient. Clinical care, with its emphasis on treating illness, is not going to get us where we want to be.

It’s been highlighted in the theses above, but it’s worth repeating here: the CDC estimates that clinical care, including tertiary care and more routine hospital and clinic-based care, accounts for only 20 percent of the factors that determine health (http://www.cdc.gov/nchhstp/socialdeterminants/faq.html). The most important contributors—about 60 percent—are social determinants such as diet, exercise and socioeconomic factors.

The bottom line is that the majority of diseases are preventable, and much is known about strategies for promoting health and preventing illness. We are only just scratching the surface in implementing evidence-based changes that could have dramatic effects on health.

Hypertension is a good example of a missed opportunity for prevention. More than half of those older than 50 have hypertension, and its prevalence increases dramatically with age (http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf ). We know how to treat hypertension; we have identified many well-tolerated drugs and lifestyle interventions that can reduce the risk of developing hypertension and improve control of blood pressure in those with hypertension. But the current system for identifying and treating hypertension is physician centric. Only doctors and limited groups of other health professionals (such as nurse practitioners) diagnose and treat it. Hypertension accounts for more clinic visits than any other condition and costs $51 billion per year in the U.S.

Even with our investment in hypertension treatment and the engagement of physicians—who are the most highly trained and expensive professionals in the healthcare system—the current system is failing. One-fifth of those with hypertension are not even aware they have it. Furthermore, just over half actually have it controlled (http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf ). If we could effectively treat hypertension across the U.S., we could eliminate a large proportion of heart attacks, heart failures, and strokes. This would have a substantial impact on health and also on expenditures for acute care.

One step further: if we encourage moderate exercise and improved diet to reduce excess weight and salt intake, we could reduce the risk of developing hypertension in the first place.

Our current approach to treating hypertension, built around doctors’ office visits, cannot achieve optimal control of the problem. It also does not acknowledge people’s desire to avoid being patients. We need an entirely new, wide-open perspective to address hypertension and the many other avoidable risk factors that have been identified for a myriad of diseases. These approaches are not difficult to imagine.

For example, a cost-saving and more person-friendly solution to hypertension management might include a system that ties a home blood-pressure cuff to a cell-phone app, which in turn channels data to a pharmacist, who then follows an algorithm set up and overseen by a hypertension expert, which allows appropriate meds to be delivered directly to the person in their home. Working at the community level, education about salt intake and exercise, coupled with simple blood pressure screening programs that link results to mechanisms for follow-up, could reduce the risk of hypertension and increase the likelihood of having it treated. This isn’t hard stuff; unfortunately, though, many population-level interventions have been tested but have not been brought to scale sustainably.

Hypertension is but one of many risk factors that could be addressed more effectively and with potential savings to society. The current “patient-focused” system is also failing us in cases involving diabetes, obesity, sun exposure and vaccination.

As it stands, physicians lead the healthcare system. They are the most highly trained and well-paid experts in health, and they represent a very broad range of backgrounds and specialties. In addition, they often do not like being led by other professionals, and some might occasionally block changes that they see as contrary to their interests. So it would be nuts not to involve physicians in the development of new models that promote health, reach out to communities, and use technologies and teamwork with other practitioners to address health needs more efficiently and effectively. Moreover, physicians are well-situated not just to participate in, but to lead these changes.

However, training for physicians today remains focused on a traditional model in which the doctor serves as a manager of the illness. This model is executed through a one-to-one relationship between physician and patient, and it is exacerbated by the underlying economics of academic medical centers and their profitable emphasis on tertiary care.

For physicians to be leaders in the transformation of the health, which is really an ecosystem challenge, this curriculum must be reconsidered or at least augmented. We need to teach aspiring doctors how to identify and execute on opportunities to improve the health system. Not everyone will become a leader in this effort, but all should learn what it means to be good leaders, and all should be ready to participate actively in the changes required to get our health system where we want it to go. We must teach leadership, system engineering, change management, methods to enhance creativity, population health, and the economics of health and healthcare.

All of this change in medicine, healthcare, and health begins with the people who practice it. We—society, all of us—need physicians and other health professionals who are focused on transforming and improving the overall system of health and health care. They need to be thinking about new opportunities and team-based solutions more broadly than ever before. They need to better understand technology and its impact on health. And they need to focus on preventive and population health in collaboration with the people they care for.

When their training is done, the financial rewards should match their success in meeting this mission for health.

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