From: "John Brady, MD" <drbrady@thevillagedoctor

From: "John Brady, MD" <drbrady@thevillagedoctor.hrcoxmail.com>
Sender: IMPcohort2@yahoogroups.com
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Date: Tue, 5 Sep 2006 14:03:21 -0400
Subject: RE: [IMPcohort2] Anatomy and physiology of a failure
Reply-To: IMPcohort2@yahoogroups.com

John W,

This has got to be somewhat depressing for you. It looks like the whole “you can lead a horse to water…” analogy. You guys did a lot to make a difference and still only half of the staff of the practices even knew what was going on. I guess this goes back to the question Gordon posed earlier. Is it possible to do patient centered collaborative care in a larger practice or does the chaos in the large practice keep the ability to innovate down? I have always felt that as docs get busier, we try to run on autopilot and have no time to really assess the needs of our patients (or our community). After seeing the results of this study, I wonder what your thoughts on this are. Can you do PCCC in a large practice, and even more importantly, can you integrate into an existing practice?

John B

From: "John Brady, MD" <drbrady@thevillagedoctor.hrcoxmail.com>
Sender: IMPcohort2@yahoogroups.com
Mailing-List: list IMPcohort2@yahoogroups.com; contact IMPcohort2-owner@yahoogroups.com
Date: Tue, 5 Sep 2006 20:51:25 -0400
Subject: RE: [IMPcohort2] Anatomy and physiology of a failure
Reply-To: IMPcohort2@yahoogroups.com

John W,

Do you think, in our capitalistic society, there will be enough motivation to change when not one penny of reimbursement rides on the outcome? Currently, we get paid for quantity only. Yes, I believe I am practicing better medicine (and through HYH I have some data to prove that), but my reimbursement and my malpractice premiums are the same as my less enlightened/higher volume brethren. What do you think will provide the impetus for most docs to change (as such an inertia would require an enormous amount of energy)? I think studies about patient outcomes and physician satisfaction are great, but unless there is a radical shift in reimbursement, I just don’t see the mainstream jumping on board even if given all the tools to try and provide much better medicine.

The vast majority of docs who listen to me discuss my practice say, “Wow, that sounds wonderful! I wish I could do that!” When I tell them they certainly can, they usually look to the ground, kick an imaginary stone, and say that they just can’t afford such a radical change in their career, BUT they love the fact that I am doing it. I have a strange feeling that a fair number of local physicians are somehow living vicariously through my practice (even if they have never met me), and yet they, for fear of cost, lost wages, loss of comraderie, or whatever, are not empowered to make a change.

So tell me what you think. How do you see us motivating the unmotivated? How do we evangelize without criticizing? How do we awaken the calling in docs who long ago stopped being healers in order to be businessmen? How do we learn from our failures? How do we change the world? J

John B

-----Original Message-----
From: IMPcohort2@yahoogroups.com [mailto:IMPcohort2@yahoogroups.com] On Behalf Of John.H.Wasson@Dartmouth.EDU
Sent: Tuesday, September 05, 2006 2:39 PM
To: IMPcohort2@yahoogroups.com
Subject: RE: [IMPcohort2] Anatomy and physiology of a failure

1. As you know, with the exception of the time series analysis of the VA performance over the period from 1995-present, most rigorous studies of what we attempt to do (large scale change in fee-for-service) have great difficulty documenting change. That is the negative spin on the "failure" story.

The positive spin is that perhaps be studying our failures we can do better.

Of note to me is how I was able to get rather impressive results from large scale practice change when I controlled the system and had a tema lof like minded colleagues...nurse, doctors, etd...(1: Wasson JH, Sauvigne AE, Mogielnicki RP, et al. Continuity of outpatient medical care in elderly men: A randomized trial. JAMA1984;252(17):2413-2417. 2: Wasson JH, Gaudette C, Whaley F, Sauvigne A, et al. Telephone care as a substitute for routine clinic follow-up. JAMA 1992;267(13):1788-1793.) For this reason I am "bullish" on IdealMicroPractices: IMPS are small enough to be controllable and efficient enough to be free of the "productivity hamster wheel."

2. However, many IMPS will fail for the same reasons that the practices we studied failed. I hope that those IMPS who find it "difficult" realize that the change first must come from within...mentally...an attitute to avoid the problems and to grab the effective tools and approaches that work.

3. Gordon and many IMPS on the list serve are emphasizing both that it can be done and how it can be done.

PS. the slides that used the "fewer than half"..type language were horribly convoluted. You seemed to have goten the idea that trickle down did not work, despite my linguistic failure.