This is a quote from Dr. Kevin Schulman, Director of the HSM program
at Duke University - Fuqua School of Business... De-Skilling I heard a great story from Mahesh Narayan about the recent trip to
India over winter break. In a meeting with Dr. Devi Shetty at NH
hospital, our HSM students were asked to look at a picture hanging on
the wall and critique it. They assumed that the painting on the wall
of such a famous surgeon would be a classic and all commented on the
work. He said an elephant in Thailand painted it and if they could
teach an elephant to paint such a lovely picture he can sure teach
anyone how to be a healthcare provider! We often talk about the tremendous scientific knowledge required in
the practice of medicine. While this is true in the aggregate, when we
break down healthcare services into specific tasks we can think about
the more limited knowledge required for that part of the equation. We use this concept everywhere in our economy - airline pilots are not
aerospace engineers designing airplanes, construction workers are not
architects, and graduate students grading papers are not professors
designing courses or research programs (not yet, anyway). Clay Christensen described this concept in an interesting way. 1He
described three different business models with different requirements
for expertise of providers. Solution shops, environments of tremendous
uncertainty where the patients coming in for care, are not
standardized and tremendous expertise is required to make a correct
diagnosis. Think “House” on television as this type of practice. Once
a patient has a diagnosis and needs a procedure, we have different
requirements for proficiency related to technical skills required for
the procedure and to manage the more limited uncertainty related to
potential complications of the procedure. He calls this a value-adding
process model. Finally, we can envision a healthcare market where
information and services flow directly between participants. He calls
this model a facilitated network model, and offers the potential for
prevention and disease management through such a model. De-skilling has several potential advantages - both on cost and
quality. Obviously, we have a significant opportunity to reduce labor
costs if we have a nurse anesthetist rather than an anesthiologist
during a procedure. We can reduce other costs as well - it might be
easier to standardize supplies and procedures with a more specialized
labor force rather than with “impresario” physicians. On the quality
side, physicians like to use their skills in facing clinical
challenges. “Routine” efforts are not as intellectually engaging and
this can result in less focused effort. This can result in lower
clinical performance scores on routine therapies like aspirin use
after a myocardial infarction. On the other hand, Rob Califf likes to
tout that McDonalds is able to train high school students to be sure
to put a ketchup packet in a take-out bag over 99.5% of the time. De-skilling also extends to information technology as a substitute for
clinical efforts. Computerized physician order entry systems (CPOE)
routinely include order sets which are really standard approaches to
clinical care. Disease management programs can substitute for
physician services in the care of patients with a chronic condition
such as heart failure. So is Dr. Shetty's elephant observation unique? Of course not. We
found de-skilling to be a critical piece of the equation in our
earlier work on Indian heart hospitals. 2In the US, we're pursuing
de-skilling every day in healthcare, but probably not as rapidly as is
possible. In contrast to the situation in Hyderabad, we have
institutionalized many processes of care within professions. This
structure becomes a significant barrier to a more rapid evolution
within the system. Interestingly, while these professions support
boundaries in an attempt to retain their core position in the market,
they are constantly trying to migrate upmarket to provide even more
lucrative clinical services within the system. Complete reform of the
system would include an effort to eliminate these artificial
boundaries tied to professional training and focus on certification in
the skills required for specific clinical tasks. The potential
physician workforce shortage in the US will be a great catalyst to
spur this type of development forward. 1Christensen, CM, Hwang, J, Grossman, J,. (2008), Innovator's
Prescription: A disruptive solution for healthcare. McGraw-Hill: New
York City 2 Richman et al (2008); “Lessons from India in organizational
innovation: A tale of two heart hospitals”; Health Affairs; Vol. 27;
No. 5; pp1260-1270.
at Duke University - Fuqua School of Business... De-Skilling I heard a great story from Mahesh Narayan about the recent trip to
India over winter break. In a meeting with Dr. Devi Shetty at NH
hospital, our HSM students were asked to look at a picture hanging on
the wall and critique it. They assumed that the painting on the wall
of such a famous surgeon would be a classic and all commented on the
work. He said an elephant in Thailand painted it and if they could
teach an elephant to paint such a lovely picture he can sure teach
anyone how to be a healthcare provider! We often talk about the tremendous scientific knowledge required in
the practice of medicine. While this is true in the aggregate, when we
break down healthcare services into specific tasks we can think about
the more limited knowledge required for that part of the equation. We use this concept everywhere in our economy - airline pilots are not
aerospace engineers designing airplanes, construction workers are not
architects, and graduate students grading papers are not professors
designing courses or research programs (not yet, anyway). Clay Christensen described this concept in an interesting way. 1He
described three different business models with different requirements
for expertise of providers. Solution shops, environments of tremendous
uncertainty where the patients coming in for care, are not
standardized and tremendous expertise is required to make a correct
diagnosis. Think “House” on television as this type of practice. Once
a patient has a diagnosis and needs a procedure, we have different
requirements for proficiency related to technical skills required for
the procedure and to manage the more limited uncertainty related to
potential complications of the procedure. He calls this a value-adding
process model. Finally, we can envision a healthcare market where
information and services flow directly between participants. He calls
this model a facilitated network model, and offers the potential for
prevention and disease management through such a model. De-skilling has several potential advantages - both on cost and
quality. Obviously, we have a significant opportunity to reduce labor
costs if we have a nurse anesthetist rather than an anesthiologist
during a procedure. We can reduce other costs as well - it might be
easier to standardize supplies and procedures with a more specialized
labor force rather than with “impresario” physicians. On the quality
side, physicians like to use their skills in facing clinical
challenges. “Routine” efforts are not as intellectually engaging and
this can result in less focused effort. This can result in lower
clinical performance scores on routine therapies like aspirin use
after a myocardial infarction. On the other hand, Rob Califf likes to
tout that McDonalds is able to train high school students to be sure
to put a ketchup packet in a take-out bag over 99.5% of the time. De-skilling also extends to information technology as a substitute for
clinical efforts. Computerized physician order entry systems (CPOE)
routinely include order sets which are really standard approaches to
clinical care. Disease management programs can substitute for
physician services in the care of patients with a chronic condition
such as heart failure. So is Dr. Shetty's elephant observation unique? Of course not. We
found de-skilling to be a critical piece of the equation in our
earlier work on Indian heart hospitals. 2In the US, we're pursuing
de-skilling every day in healthcare, but probably not as rapidly as is
possible. In contrast to the situation in Hyderabad, we have
institutionalized many processes of care within professions. This
structure becomes a significant barrier to a more rapid evolution
within the system. Interestingly, while these professions support
boundaries in an attempt to retain their core position in the market,
they are constantly trying to migrate upmarket to provide even more
lucrative clinical services within the system. Complete reform of the
system would include an effort to eliminate these artificial
boundaries tied to professional training and focus on certification in
the skills required for specific clinical tasks. The potential
physician workforce shortage in the US will be a great catalyst to
spur this type of development forward. 1Christensen, CM, Hwang, J, Grossman, J,. (2008), Innovator's
Prescription: A disruptive solution for healthcare. McGraw-Hill: New
York City 2 Richman et al (2008); “Lessons from India in organizational
innovation: A tale of two heart hospitals”; Health Affairs; Vol. 27;
No. 5; pp1260-1270.
