The Future of Health Care Globalization

by Steve Thompson on July 18, 2014

Most of us have at least a rough sense of what globalization means when it comes to cars, movies, vegetables, and information technology. But what does it mean when it comes to health care?

A Google search on “health care” and “globalization” mostly leads to articles that focus on medical tourism, which is when patients travel—sometimes across the world—to receive treatments. When patients travel for care, sometimes at the urging of large employers or whoever is paying for the service, it’s typically to receive treatment at a discount from what it would cost near their homes, though sometimes it’s to receive treatments that aren’t available locally, or that in some way aren’t delivered as well.

But as I’ve written here in this blog and elsewhere, medical tourism isn’t the big trend it’s been anticipated to be, and it will likely become even less important. That’s because we’ll see the worldwide gaps in health care prices, availability and quality start to shrink, as countries with advanced health care systems grapple to control their costs, and other countries improve quality and access. The result is that more people will be able to get the treatment they need more locally at costs that aren’t terribly out of line with other places in the world. This is a very good thing, because people who need medical treatment shouldn’t have to add the burden of travel to their already challenging situations.

Also turning up on Google under search results for health care globalization, but in a distant second place, is the idea that physicians, nurses and technicians will move to other countries to work. That is, health care professionals are to some extent becoming exports via immigration or expatriation. That’s a trend that’s been going on for a long time, and will likely continue for the foreseeable future, given mismatches in various countries’ health care demands, labor costs, employment levels, and training availability, among other factors. But whether it’s a good representation of globalization is another question.

Health care globalization will ultimately be about the more fluid flow of services, expertise and information across borders. That particular interpretation of health care globalization is scarce among the Google search results. A small exception is the World Health Organization’s website, which while it more prominently cites medical tourism and immigrant/expat health care labor as examples of globalization in health care, also includes these three lines as defining the trend:

The increase in private companies, including foreign companies, which provide health services and health insurance schemes.

The use of new technologies, such as the Internet, to provide health services across borders and to remote regions within countries.

....Openness to foreign goods, services, ideas and policies, and people.

Buried in those few words is a world of opportunity to improve health care around the planet, and one that could go far beyond sending patients to other countries for hip replacements or importing nursing staff. Therein lies the future of health care globalization: Collaborations between private health care organizations, insurers, NGOs, government agencies, academic centers, investors and others, coming together across borders to sustainably expand and improve health care systems.

Those collaborations can involve the flow of experts who visit to help design and develop hospitals and clinical programs, of procedural and physical tools that enable improvements, of telemedicine that augments local capabilities, of private investment to support new projects, and of managers who can teach others how to keep things running smoothly. We at Johns Hopkins Medicine International have been helping to provide and orchestrate these sorts of collaborative services in dozens of major health care projects all over the world for two decades, and more and more of our fellow academic medical centers and other organizations are joining in.

Yes, we’re also involved in helping patients who travel internationally for treatment, and in bringing in staff who come from other countries to work at our hospitals and projects. Sure, that’s part of globalization. But health care globalization at its best will be about bringing a vast range of international resources to bear on comprehensive local solutions. It has been exciting for us at JHI to help pioneer that trend, and I look forward to watching it grow in the coming decade.

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The Journal of the American Medical Association recently published a study entitled “The Global Slowdown in Health Care Spending Growth.” The study looks at spending data gathered in a report from the Organization for Economic Cooperation and Development, and observes the following about “excess health care spending growth,” or growth in health care spending that exceeds the growth of the economy:

In recent years, rates of excess health care spending in the United States and OECD have declined below their historical norms; in 2010 and 2011 (and 2012 for countries with available data), excess spending was either negligible or negative. The slowdown in health care spending growth has been a global phenomenon; in fact, US excess growth in 2010 and 2011 was slightly higher than average relative to other industrialized countries.

The article doesn’t specify which countries are included, other than to say it’s the OECD countries with data from 1980 to 2011. Apparently it relied on a list found in the OECD report. Excluding countries without data from 1980 to 2011, that leaves 23 countries—23 of the most industrialized, affluent countries in the world.

Because these 23 countries have long boasted extensive health care systems, and can with their affluent populations afford heavy infrastructure investment, they do of course constitute the lion’s share of health care spending in the world. Thus it’s perfectly accurate to say a slowdown in spending from these countries represents a global slowdown, because what these countries do will swamp whatever is happening elsewhere combined in terms of total spending levels.

But at the same time, calling the slowdown a global one is a bit misleading. It may be “global” in terms of total spent, but I suspect that if you looked at all countries around the world, and weighted spending growth by size of population covered rather than by absolute spending amounts, the results would be very different. (I wish I had the data at hand to make this calculation, but the availability of data is heavily biased toward the industrialized countries.)

In fact, I’d bet a more comprehensive, population-based look at global spending (that is, average percentage spending increase per capita) would reveal a global increase in health care spending. After all, that larger list of countries would include some pretty populous nations that have seen vigorous growth in health care investment in recent years, including China, India, Brazil, and in fact almost all of Asia and South America, where investment growth in health care (and infrastructure in general) has been strong. Many countries in Africa, too, have been investing. The great majority of countries in these regions are not on the list considered in the study—a pretty big group to leave out.

The world as a whole is seeing more and better health care. The most industrialized countries may be lagging in that growth in recent years, but that means the less- and more-recently industrialized worlds are working to close the health care gap. You’d expect a steeper growth curve for countries that have been relatively lacking in modern health care infrastructure, whereas mature systems like those found on the OECD list are more likely to take a breather from rapid growth, especially as they try to limit health care costs.

Accelerating that closing of the spending gap is the fact that global investment has been shifting to emerging and less-fully industrialized markets, as these countries build their infrastructures. What’s more, we’ve been seeing a mostly steady rise in democracy, larger middle classes, and better access to education and information in these markets. Many of these populations now for the first time can afford modern health care infrastructure, are aware of what they’ve been missing, and have the political clout to demand improvement. We’re seeing these trends in just about every less-fully industrialized region in the world.

None of this is to say the study was inaccurate, including in the way it used the term “global.” But I hope observers will avoid labeling health care trends that apply only to highly industrialized countries as “global” trends. It may be accurate to do so as a matter of numeric averages. But it tends to mask the large and important changes in health care taking place among a huge percentage of the planet’s population—a trend that should be celebrated, not obscured.

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Too Much Medicine? Not Necessarily

by Steve Thompson on July 14, 2014

A recent journal article examined the issue of “overmedicalizing,” or handling a normal human condition as if it were a disorder requiring medical treatment. Claims of overmedicalization have been made about several conditions. For example, attention deficit hyperactivity disorder (ADHD) may be a brain condition treatable with medications and therapy—or a label wrongly attached to a normal set of cognitive and personality traits. Aging and death are natural processes that call for little or no medical intervention—or ones that can be staved off or mitigated by treatment.

Some claims can seem reasonable and should give us pause, for example, people very near the end of their lives receiving aggressive treatment rather than palliative care. In other cases, we should be wary of the claim, because treatment can truly lengthen life span and raise the quality of life. As an example, consider the fact that through the 1980s and beyond, some loud voices insisted that AIDS was a syndrome caused by drug abuse, and not a viral condition that might be treatable.

Clearly this issue can be complex. Consider the role of culture in whether a situation might urgently call for medical intervention. In the U.S., for example, many would agree that a cancer drug capable of adding six months or so of high-quality life to a patient’s prognosis ought to be an essential treatment. But some Johns Hopkins Medicine oncology faculty who have spent time practicing at Johns Hopkins Singapore have been surprised to find that not all patients there feel the same. What is considered good medicine here in the U.S. might be considered overmedicalization in other cultures. We’ve learned to respect these sorts of differences, which we encounter all over the world.

People tend to speak of health care as if it necessarily looks at all patients’ problems as being candidates for medical treatments. Historically, that’s probably a fair claim—health care systems have indeed been biased toward treatment, and usually in hospitals and doctors’ offices. But that’s changing, and quickly. Increasingly, health care is spreading out from the hospital to the community and even the home, reaching people not just with medication and procedures but also with education and support services that promote healthier lifestyles and prevention. Health care wants to do more to keep patients from needing to be in hospital beds, or from even requiring any treatment or special care at all.

As that transformation to “the bedless hospital” continues, and medicine becomes as likely to provide emotional support, dietary advice and healthy-habit coaching as it does medication, concerns about overmedicalization will become less urgent. The question won’t be whether medicine should be involved in a problem, but rather what flavor of medicine should be involved.

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Health Care Communitarianism in Colombia

by Steve Thompson on June 23, 2014

FSFB

There is no one institutional path to becoming a provider of high-quality, safe, affordable health care. It’s not, for example, about private vs. public, or profit vs. non-profit. Rather, it’s about being mission-driven, structuring for sustainability, and building around local culture and needs. In our collaborations with health care providers, payers and government agencies around the world, we at Johns Hopkins Medicine International (JHI) have worked with different models for how care is paid for and delivered. We’ve seen that any model can succeed or struggle, depending on the context and implementation.

Actually, there’s one model we don’t often encounter in our global collaborations—the one we follow at Johns Hopkins Medicine. The model is that of the academic medical center, dedicated to providing not only top-notch care, but also medical education, and to advancing the state of medicine through research. Our model also involves a commitment to expanding the scope and accessibility of medicine everywhere through our work in public health and our efforts at JHI.

But one global collaborator of ours that follows much the same model is Fundación Santa Fe de Bogotá (FSFB), in Colombia. And, though much of what FSFB does is similar to what we do, the differences in regional context lead to some sharp contrasts.

For example, here in the U.S., Johns Hopkins Medicine is one of many fine academic medical centers. Though we strive to deliver the very best care to patients, we can’t claim that most patients who come here from Maryland, or from other parts of the U.S., don’t have several options for good medical care. But in the Bogotá region and to some extent in all of Colombia, FSFB is a unique institution, offering care and services that many in the region wouldn’t be able to get anywhere else. Unlike Johns Hopkins Medicine, FSFB can’t draw on the resources of a vast, longstanding, advanced medical infrastructure to grow and maintain its capabilities. Since its founding in 1972, FSFB has not merely reflected the progress of Colombia’s health sector; it has been instrumental in defining that progress.

Because JHI collaborates with FSFB, I’ve had the pleasure of getting to talk to that organization’s dynamic leader, Juan Pablo Uribe. I find it inspiring how seriously he and all the leadership of FSFB take the responsibility of advancing the state of medicine and health care in their region and country. Anyone who knows Dr. Uribe’s background would expect no less: A former World Bank senior manager focusing on health care, he held posts in Colombia as the vice minister of health and the national director of public health before taking the helm at FSFB.

For Dr. Uribe, FSFB’s role is more than just a health care mission: It’s a world view, one that he likes to refer to as “communitarianism.” That’s a term with some history in political and social movements and in philosophy, but the essence of what Dr. Uribe means by communitarianism is when local, private institutions become important not merely in providing useful services to the public, but in shaping the community.

That drive to impact the community in ways that do the most good is clear in many of FSFB’s efforts. It established a Community Health division that focuses on improving environmental health factors in Bogatá’s most vulnerable communities through education, training, social mobilization, direct intervention and policy. It established the Center for Studies and Health Research to advance medicine’s understanding of and ability to control infectious and other diseases that are a particular burden to the region, including malaria and dengue. It has helped design and implement systems for monitoring health outcomes for Colombia, and has been a pioneer in applying health economics and technology to bettering health care delivery. It has been continuously involved in forming local and national health policy, including the design of comprehensive health care plans.

Of course, FSFB’s commitment to improving health among those who most need it is best exemplified by the care it directly delivers. Its University Hospital was the first Bogotá-region hospital to receive Joint Commission International accreditation, and the second in Colombia.

FSFB has been at or near the forefront of virtually every one of the country’s medical advances for three decades, performing the first liver and cardiac transplants there, providing start-of-the-art imaging, radiosurgery and neonatal care capabilities, and establishing Colombia’s first emergency clinic and one of its first intensive care units. Its institutes of oncology and cardiovascular disease are at the tops of their fields. And it has been a leader in the country in emphasizing the importance of advanced nursing practices to good health care outcomes.

Meanwhile, FSFB’s faculty has generated more published medical research than any other institution in the country, much of it in collaboration with counterparts elsewhere in Latin America and in the Caribbean.

All of JHI’s collaborations are two-way streets, enabling us at Johns Hopkins Medicine to not only share our expertise but also learn about medicine in different cultural and health contexts. In the case of FSFB, the collaboration has inspired us to reflect on our mission—and remind ourselves that no matter how much we do to improve health and advance the field of medicine, there is so much more to be done.

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Empathy

by Steve Thompson on May 23, 2014

EmpathyAt a recent Johns Hopkins Medicine International (JHI) staff meeting, we viewed a brief but powerful video created by the Cleveland Clinic that aims to evoke empathy for a fictional set of hospital patients, families and staff. A moving illustration of the need for empathy in health care, the video has gone viral online, garnering nearly a million and a half views.

While all of us at JHI are involved in working to improve health care delivery, most of us aren’t currently front-line clinicians, nurses or other caregivers routinely working directly with patients. But some of us are, and I assumed those folks would find the video particularly impactful. So I was surprised when, after the meeting, the highly experienced nurse care manager at JHI, Teresita Achanzar, expressed skepticism about the ability of this and other efforts to transmit the true nature of empathy in health care.

Teresita argues that genuine empathy for patients—a level of empathy that allows understanding what they’re going through well enough to be able to meet their needs and adequately support them—can only be learned one way: from the patients themselves. She offers a very simple, straightforward form of observational evidence to support her claim. Namely, she says that a good number of the newly minted nurses she’s worked with over the years, as much as they may sympathize with patients, have lacked that empathy when they start. It doesn’t matter what kind of person they are, or how they’ve been trained, or where, she says. They may be highly empathetic people in general, but when it comes to truly connecting to patients’ needs and challenges, they often fall short.

Part of the problem, Teresita explains, is that when they first land in hospitals after nursing school they have their hands full managing the mechanics of their jobs—mastering the different systems and routines and handling the countless problems that pop up in a patient population in the course of a day. They just haven’t ever had time, occasion or context to focus on relating to what patients are thinking and feeling.

But after a few years, most end up gaining that deep empathy, she says. That’s partly because of the on-the-job training and mentoring they’ve received from their managers and other colleagues, but it mostly comes from constant contact with the patients. Patients tell you how they’re feeling and what they’re thinking, she says, because they need you to understand. Over time, you learn to see it in their expressions and body language, and hear it in the tones of their voices. You can’t help but get it. And you can’t help being affected by it, and wanting to do what you can to help.

Teresita adds that all the challenges of acquiring that deeper level of empathy are magnified in international health care work. In the case of the many international patients who come to the Johns Hopkins Hospital in Baltimore, for example, there are often language barriers, a dearth of family members who can help bridge communications gaps, and cultural mismatches that may lead to clinicians or nurses unintentionally offending or confusing patients, or vice-versa.

In the case of the many hospitals around the world with which we collaborate, there may be cultural contexts that cause patients to hesitate to be fully open with some caregivers—for example, cultures in which women are discouraged from speaking up, or in which elderly patients expect that their children will shield them from decisions about their illness, or in which beliefs in traditional medicine lead to skepticism or fear of modern medicine.

Yet these and other barriers, too, ultimately give way to the process by which caregivers acquire empathy for patients, Teresita insists. Those patient-caregiver bonds form everywhere in the world, she says, and under the most trying of circumstances.

I’m sure many millions of hospital patients, former patients, and family members all around the world would join me in feeling gratitude for that process.

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By Juan Carlos Negrette, Managing Director, Johns Hopkins Medicine International

Since its creation, Johns Hopkins Medicine International (JHI) has been actively involved in emerging economies, well before these markets came to be considered attractive to the investment community. For many years now, JHI has had active and vibrant collaborations in economically growing Latin American and Eurasian nations such as Colombia and Turkey, involving us in a broad portfolio of relationships in countries with vast economic and social differences—but all of them united by their need to improve patient care.

Eclipsed by the fast development in other geographic areas, Africa remained for a time at the edge of JHI’s peripheral vision. However, faithful to its ethos of looking in a less-orthodox way at health care market possibilities, JHI a few years back started actively considering the untapped potential in Africa as a diverse region blanketed with pressing health care needs. Sub-Saharan Africa accounts for 11 percent of the global population yet bears 24 percent of the global disease burden, while only accounting for 1 percent of the global health expenditure.

This disproportionate relationship between the continent’s needs and invested resources has no doubt contributed to some of the health-related calamities that are periodically highlighted by the international press. This calamitous image is perhaps the best-known face of Africa. But stubbornly as that image has persisted, a more accurate and auspicious one has begun to emerge alongside it: namely, the image of a continent crowded with resilient people that, in spite of real challenges, has come to house several of the most dynamic economies in the world.

Before JHI became involved in collaborations in Africa, we looked at the intense demographic changes the region was experiencing, and the unique economic dynamics at play there. We also observed the region’s existing health care infrastructure and workforce, which are sorely lacking compared to those of most other countries. These are the same characteristics that any health care investor would examine, but we brought a different perspective to the task—a perspective that went beyond simply avoiding significant risk, and that instead was biased toward recognizing opportunities that might have an impact on health in the region, with the requirement only that the attendant risk be manageable.

Our belief in health care investment opportunities in Africa has been validated. Today the economies of Nigeria, South Africa, and other African countries are among the top 30 largest of the world. A rapidly growing middle class is now a common feature throughout the region. The notion that Africa is an economic and health care “basket case,” as many once claimed, has been proven to be a shortsighted view, belied by the vibrant expansion now taking place there. We see enormous opportunities in Africa for us and other players in the global collaborative health care industry, such as a chance to create new institutions to address medical, nursing and technical education, and to advance clinical care, and in ways likely to improve social well-being.

JHI has already taken the first steps in forming strategic collaborations and partnerships, including an agreement to participate in the building of a string of clinics in Nigeria. Our discussions with potential collaborators are taking place not only in the largest and most advanced economies in Africa—they are literally all over the map. Where once we could only say that we had hopes for Africa, now we can say that we are executing on opportunities there. We're confident that other investors, academic medical centers and institutions involved in global collaborative health care will be joining us in greater numbers, and with ever larger commitments, in the coming months and years.

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Revisiting ‘Medical Tourism’

by Steve Thompson on May 12, 2014

It was nice to see The Economist weigh in with a brief examination of the “medical tourism” market that echoes themes I’ve emphasized before, even going back to one of my very first posts. I’ve long argued that there isn’t a lot of substance to the much-hyped notion that millions of patients would seriously consider traveling overseas for relatively routine and sometimes expensive medical procedures to save money while enjoying an exotic vacation, and the article backs me up on this.

The article points out that, for starters, the data thrown around by medical-tourism boosters has been muddled:

In 2008 Deloitte predicted an “explosive” boom in medical tourism, saying that the number of Americans going abroad for health care would grow more than tenfold by 2012. It did not happen. Poor data were part of the problem: whereas Deloitte counted 750,000 American medical tourists in 2007, McKinsey, another consultancy, found at most 10,000 a year later.

I would add another observation related to the problems with data in this field. To the limited extent that there are patients who get routine procedures far from their native countries, many are ex-pats who are living in or close to the country where they’re being treated, not people who have traveled far specifically for care. In other words, there isn’t a useful definition of what a “medical tourist” is. That fact alone ought to cast doubt on claims about the size of the industry, including those made by hospitals advertising themselves as centers of medical tourism.

I don’t mean to deny that the industry exists. It’s true that significant disparities exist from country to country in the costs of some treatments, and there really are opportunities for some patients to travel to get good care at lower cost.

But this observation needs to be heavily qualified. First, globe-hopping for medical treatment is likely to make the patient’s experience more challenging. Patients undergoing treatments—especially the more costly, extensive ones that someone might travel for—are vulnerable to pain, discomfort, depression, loneliness and anxiety both before and after the procedure. Certainly attentive, empathetic, highly trained hospital staff can help patients cope, and we work hard here at Johns Hopkins Medicine to do that for our international patients.

But patients also appreciate the presence of family and friends, and a chance to be back in their homes as soon as possible. As the Economist article notes about medical tourism:

Patient interest also turned out to be lower than predicted. Though some patients in the rich world seek out deals, most receive adequate health care at a manageable price and would prefer to stay at home. Potential savings are often insufficient to trump concerns about quality and the lack of recourse if something goes wrong. In 2008 Hannaford, an American supermarket chain, offered to pay the full cost of hip and knee replacements for its employees, including travel and patients’ usual share—provided they would go to Singapore. None took up the offer.

The article also points out that 98 percent of medical costs go to treatments that don’t readily lend themselves to the delays and stresses of travel. And it adds that even with the sort of short, relatively hassle-free travel faced by European patients who want to get medical care in another European country, cross-border health care accounts for only 1 percent of public health care spending.

The other qualification I would make is that even in those cases where medical tourism might make sense today, there will be fewer of those cases moving forward. Medical tourism is a transitional market—it’s a short-term response to the large changes roiling health care industries around the world. Right now we’re at a stage where patients in the United States and some other highly industrialized countries face much higher prices for some treatments than patients in other countries, even though the quality of treatment isn’t always that much better here.

But because of the Affordable Care Act (ACA) and other efforts to reform health care in the United States, costs here may well come more into line with the rest of the world, and quality and outcomes are likely to improve. In addition, the ACA should ensure that fewer Americans find themselves with insurance gaps that necessitate large out-of-pocket costs for treatments.

Those sorts of improvements, and not medical tourism, are the longer-term, more steady-state solution to the cross-border inequities in availability, quality and cost of medical care. That’s one of the reasons the world has seen the rise of the new global collaborative health care industry that we at Johns Hopkins Medicine International are proud to be a part of. Global health care leaders are working to identify ways to more evenly distribute top-notch health care resources and facilities to all populations. Everyone with a role in health care—from investors to academic medical centers to governments to NGOs—also has a collaborative role to play in this new field.

There may always be certain complex, highly advanced procedures that patients will have to travel for. But as global collaborative health care efforts progress, we should see fewer of those—just as in the United States, we’ve seen once-daunting procedures such as common forms of cardiac surgery migrate from top medical centers to community hospitals.

An extensive medical procedure won’t ever be much fun. But it can be less of a burden when it takes place close to home. I hope more of us in health care can work together to make that happen for patients around the world.

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Nursing is a linchpin to health care success, Johns Hopkins Medicine International has found again and again as we help collaborators around the world sustainably improve health care systems. Raising the level of nursing catalyzes improvement throughout the systems in ways that strongly impact every aspect of the quality and safety of patient care.

Research backs that up. For example, The American Economics Journal: Applied Economics recently published a study that looked at 900,000 patient admissions, and found that patient outcomes on average measurably improved when the nurses in a patient’s unit were more experienced and had more training.

Most of us in health care wouldn’t be surprised by those findings. For a few centuries now, nurses have provided patients with broader, more continuous bedside support than physicians can usually hope to offer. Nurses typically spend more time physically closer to the patient, which means they’re often quicker to spot changes in the patient’s status. They can observe a patient’s mood and level of comfort, interact more, and become more familiar with the patient’s family and lifestyle, all of which can enormously affect a patient’s recovery.

No wonder then that health care safety and quality improved in the United States a few decades ago when nurses started to become regarded as full and equal members of the clinical care team alongside physicians. And the importance of nursing to patient care increased all the more when medicine cut down on the long shifts that physician interns and residents traditionally had to endure. Today patients can rarely expect to be monitored by the same physician throughout the course of an entire day, which means it’s largely up to the nursing staff to maintain a sense of how a patient’s condition is trending over the hours. And nurses not only deliver patient care, but also play a strong role in research, health care innovation and public health, as this article on Johns Hopkins nursing “heroes” illustrates, along with this article on a Johns Hopkins nurse practitioner’s work in the Caribbean.

And now there are new reasons nursing will be even more important in the future. As health care systems look for ways to deliver better care to more patients at lower cost, nurses may need to take over many of the responsibilities that have traditionally belonged to physicians, such as administering routine tests, providing nutritional counseling and answering patients’ questions. Here in the United States, the Affordable Care Act is pushing for those sorts of changes. As this article relates, the U.S. government has already earmarked some $50 million in nursing-education grants to help address a predicted shortage of at least half a million nurses a decade from now.

As challenging as it is to develop nursing to its full potential in the United States, it can be an even more daunting task in many of the countries in which we are working. (There are even nurses who work between countries, as this article explains.) Some countries have lagged behind the United States in elevating the status of nurses, and bridging that gap can be tricky—and this in addition to the fact that the demands on nurses in these countries can be especially high, given that physicians may be in shorter supply. To address these challenges, we’ve established a range of programs that involve not only conventional training, but also nurse exchanges, mentoring, leadership development, team building, culture change and much more.

As a result, the health care systems with which we collaborate globally have made great strides, even while we at Johns Hopkins Medicine’s Baltimore-area hospitals strengthen our commitment to having nursing play an ever larger role. It’s an ongoing effort, and one we know will pay off for patients everywhere.

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Moving Beyond the Jellyfish Model of Health Care

by Steve Thompson on April 25, 2014

In some regions of the world, elderly family members may be shielded from knowing that they have been diagnosed with a terminal illness. These patients are sometimes brought to clinics with upbeat, generic names, so that they can be cared for without ever having to know that they are terminally ill.

Johns Hopkins Medicine International is committed to respecting cultural differences in the many countries in which we collaborate. But this particular cultural norm—while well intentioned—is challenging for us. Medicine in the United States and most of Europe has become committed, as a matter of ethics, to being open and honest with patients. We at JHI share that belief, and support our collaborators in adopting the same approach. (They all do.)

But even in the United States, it wasn’t always as clear that clinicians should be transparent with patients. A few decades ago, many U.S. physicians would “protect” patients from learning about troubling diagnoses. They gave sugar pills under the guise of prescribing treatments, to fool patients into feeling they were being helped when in fact there was no treatable diagnosis.

More generally, physicians usually called the shots when it came to tests and treatments. This idea that health care is entirely up to the doctors is sometimes referred to as “medical paternalism”—the notion that medicine knows what’s best for you. I call it the “jellyfish” model of medicine: The patient is expected to passively float, pushed in whatever direction the health care system deems appropriate.

It’s different today. Many patients will research their symptoms and want to discuss diagnosis and treatment, and physicians consider them a partner in the decision-making. In hospitals, patients are now seen as full members of their clinical-care team.

That’s the way it should be. There are real downsides to the jellyfish model of health care. First, when patients aren’t encouraged to become involved in their own health care, they’re more likely to fall short when it comes to adopting healthy lifestyles. Second, it can lead to higher costs. As I’ve written here before, patients who don’t know what their treatments cost the system, and who have no incentive for caring, often end up with more expensive procedures than alternatives with the same benefits.

It makes sense for patients to be fully informed, so they can be smart shoppers. We’re already seeing the ground being laid for more of that in the U.S., with the rise of retail health care in the form of urgent-care store-fronts and pharmacy clinics, among other changes.

Cultural preferences for keeping family members in the dark about their health is not the only tricky issue raised by the drive to better inform and involve patients. The U.S. Food & Drug Administration recently stopped the sale of a popular personal genome-test service marketed to consumers, arguing in a statement “that patients relying on such tests may begin to self-manage their treatments through dose changes or even abandon certain therapies.” In other words, efforts to give certain types of difficult-to-interpret personal-health information could lead patients to cut doctors out of the decision-making loop in ways that could be dangerous. (The Journal of the American Medical Association weighed in on the question here.)

In spite of such thorny questions and the tensions that arise over any sea change in health care, clearly the widely accepted trend is to favor patients getting ever more information and being ever more active in their health care. It’s a trend we push for in our international collaborative work—one that our collaborators embrace. Medicine should never abdicate its role of helping us understand and act on health information, and we have to hope that patients recognize the need to listen to their doctors as part of the process—especially when it comes to medication. But rarely is there a real need for medicine to “protect” us from learning too much about our health.

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Ron Lavater

From 2009 until a few months ago, I had the honor of serving as the Johns Hopkins-appointed CEO of Corniche Hospital, a bustling maternity facility in Abu Dhabi. Reflecting back on my time there, I recognize our work as a useful case study on how teams of experts from different parts of the globe, from both the public and private sectors, can collaborate around making a very good health care institution one of the best in the region.

This, of course, required navigating a largely unprecedented blend of cultures, medical practices, organizational styles and financing methods in order to raise health care standards to the highest possible levels, especially in a region where relatively few hospitals have yet achieved them.

Corniche Hospital opened at its present site in 1984, and went on to become the busiest tertiary maternity and neonatal service hospital in Abu Dhabi, with close to 9,000 births and 1,000 neonatal intensive care unit (NICU) admissions. The hospital also provides some 120,000 outpatient visits, 25,000 urgent care visits, and 12,000 inpatient admissions for its specialties of obstetrics, gynecology and neonatology.

Corniche Hospital is owned and operated by the Abu Dhabi Health Services Company (SEHA), a quasi-governmental entity. Corniche’s collaboration with Johns Hopkins Medicine began in late 2008 with the signing of a five-year management agreement. At that time, the hospital’s reputation in the community was positive, although SEHA recognized that Corniche needed advancement in several key areas, including evidence-based clinical practice, quality improvement, physical facilities and management practices. An experienced team of Johns Hopkins executives assumed four key administrative positions at the hospital (chief executive officer, chief operating officer, chief medical officer and chief clinical officer). From the beginning, our mandate included establishing a plan not only to transform Corniche Hospital, but to smoothly transition direct management of the hospital back to SEHA in a sustainable way that prioritized developing local talent.

Our collaboration addressed changes in every aspect of the hospital, including people, processes and physical plant. For example, we upgraded the 50-bed NICU with state-of-the-art equipment, and doubled its physical size, adding proper spacing between patients, and providing for 14 more beds. We addressed patient flow by establishing an off-site women’s health center, bringing services closer to our patients. Together, we accomplished these and other projects, including much-needed medical technology additions and upgrades, on plan and on budget.

In patient care, the challenge was to establish best practices that were compatible with local culture, as well as instituting training and mentoring programs. We brought in a stream of world-class clinicians to provide seminars and classes, to work with Corniche Hospital staff to establish and codify new practices, and to conduct rounds alongside staff to facilitate knowledge-sharing. We emphasized embracing a culture of safety. We joined the Patient Safety Net reporting system run by the University Hospital Consortium and adapted locally many of the established Johns Hopkins patient safety programs, such as administrative patient safety rounds.

Image Credit: Ahmed Kutty/Gulf News

We expanded subspecialization clinical services in fetal medicine, assisted reproductive services and maternal medicine. We added respiratory therapy and a clinical pharmacy in the NICU, and strengthened our high-risk obstetrics, lactation, diabetes, dietetics, parent education and physiotherapy areas. As a tribute to these improvements, Corniche Hospital’s medical team safely delivered the UAE’s first live sextuplets, drawing on the skills of more than 25 staff members from a range of specialties.

We also expanded our efforts beyond the four walls of the hospital to have an impact in the community, putting public health initiatives on the management agenda. The hospital recruited Abu Dhabi’s first hospital-based public health director, and developed the first sustainable newborn car safety seat program in the Gulf region. Today, Corniche has distributed more than16,000 infant car seats to parents, who were also educated on the safety benefits of infant car seats. Other public health campaigns focused on pre-pregnancy wellness and screening for cancer, adult diabetes, and newborn audiology and congenital heart disease.

Recruiting top-quality clinical staff is challenging for most hospitals, but when 97 percent are expats from around the world, it’s even more difficult. To address that challenge, we mapped out a plan to develop clinical training programs around our core competencies, creating a pipeline of future caregivers. This strategy also linked to our strategy for developing Emiratis as clinical providers, to build a local talent base.

Corniche Hospital became the first facility outside of the United Kingdom to be recognized by the prestigious Royal College of Obstetrics and Gynecology for providing advanced training skills modules in maternal and fetal medicine. We established a specialized NICU nursing education course that allows nurses to complete a six-month neonatology nursing certificate program recognized by the local licensing agency. We also inaugurated a bachelor’s of applied science in midwifery program in partnership with the Higher Colleges of Technology of Abu Dhabi, an 18-month program that is the first of its kind in the UAE. Working in tandem with another Johns Hopkins-managed hospital in the UAE, Tawam, we created a three-year neonatal fellowship. And, we established a new obstetrics and gynecology residency program recognized by ACGME International.

(from left to right) Bassam Sayed, COO; Judy Lee, M.D., CMO; Lynda Mikalauskas, CCO; and Ron Lavater, CEO accepting the Circle of Excellence Award

All of these changes have helped lead to a string of prestigious regional awards for hospital staff in recent years, including Best Hospital from SEHA, and Excellence in Patient-Centered Care from the Arab Health Awards.

Meanwhile, the project had all along been laying the groundwork for the smooth exit of Johns Hopkins from the daily management, so SEHA and local managers could assume leadership of the hospital. With proper planning, and a great deal of communication that included town hall meetings, that transition went off without a hitch at the end of December. Though it may sound unusual to say it, I’m very proud of having worked myself out of a job—it’s the ultimate measure of our success—and I know my colleagues feel the same way.

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