Learning Impaired

Two days from now a new report will be released by the Institute of Medicine (IOM) on creating learning organizations in healthcare. The wag in me says that this is an oxymoron. One of the main lessons I've learned in being in hospitals over the last 25 years is that they rarely learn anything and if they do, they learn painfully slowly. Thus, I've come to regard the whole system as "learning impaired" from the standpoint of being able to realistically change its behavior or learn from itself. Case-in-point, we have talked endlessly about making decisions on the basis of empirical evidence (evidence-based medicine), yet day in and day out in practice I interact with prescribers who do not know and/or follow guidelines from the late 1990's! The learning impairment comes from many places in my humble opinion - I'll highlight my top 3. The first is the overall focus on dollars rather than outcomes. When the obvious focus is on running a business, then everything else is secondary. Until this is redefined, the system will not change it's focus. Secondly, physicians have always practiced autonomously - even though their decisions drive the costs in healthcare. I had a pulmonologist (lung doctor) tell me honeslty a few years ago that he knew he was supposed to treat asthma a certain way, but though he might see 6 persons with this disease a day, he would probably treat them at least 3 different ways. Until all physicians (and other prescribers) are held to strict treatment protocols, there will be no functional learning (it will just be personal bias). Finally, physicians always treat lawyers first prior to treating patients. Decisions are based on risk mitigation for litigation, not necessarily on what is best for the person. Learning can not happen until tort reform is enacted (not going to happen when approximately 2 out of 3 legislators are lawyers). I applaud and agree with the IOM's conviction that healthcare needs to become a learning environment. However, the forces aligned against this are formidable, and a think-tank like the IOM can not change this. ACA (aka Obama-care) takes us a number of steps in the right direction - and while certainly not a panacea, it will move us a bit towards the goals we'd all like to see healthcare learn to achieve. Peace for the journey, Dan