Swim the Avalanche

I HAVE LEARNED MUCH during almost two decades of pediatrics in clinical and administrative roles in the Permanente system. My organization has done very well, and I am grateful to have had a part in shaping that success.

But whether I am getting old or just crusty, I have begun to feel that the problems facing healthcare and the practice of medicine are not likely to be solved well (or any time soon) from within large, isolated, insulated and competing systems. As much as I believe in the way my organization delivers care, my interests (and my hopes) have shifted toward an integrated community of several large systems complemented and enhanced by a host of independent group and individual practices.

I like to hit the ground running, and have tried to use the President-Elect year to advantage. I attended all major SSVMS committees and met the incredible people who make them run. I sat down with key representatives of all four major health systems and the Woodland Clinic, building a base for discussions about common issues and how we can begin chipping away at our differences. And along with other physicians and staff, I helped develop a recruiting process that resulted in almost 100 new SSVMS members since August, an 8 percent increase. So what's next?

The problems facing us are painfully clear: seven million people in California without health insurance, a number likely to grow; exploding regulation of medical practice, decreasing reimbursement rates, overwhelming flow of information; burdened and disenfranchised physicians, many leaving practice early; health care costs rising quickly; Baby Boomers about to add significantly to the burden of care; no new money in state budgets for the foreseeable future; bioterrorism poised to throw the entire system into complete overload and disarray within a matter of hours. There is no lack of critical issues to work on.

This list — now quite familiar — has an abstract and distant feel. But the issues are potentially very personal. Ask yourself: Will you be able to find care when you need it? Will you be able to afford it? How long will you have to wait for it? Will that wait be too long to help you? Or, if those questions don't grab you, apply them to your parent or child. Will she be able to find needed care? Will he be able to afford it? How long will they have to wait, and will that make it too late to help? These are uncomfortable questions, but potentially affect us all.

The good news is that the issues finally have the attention of the public, the media and the legislature. The train is leaving the station, and healthcare will be in the forefront at local, state and national levels over the next couple of years. In California there are already at least two proposals for universal health coverage. One of these — or a hybrid — could soon become law.

With the train leaving the station, it is important for each of us to get involved. We cannot afford to limp off into our respective corners and complain about bad officiating, bad luck, or how things used to be. We cannot afford it personally, and we cannot afford it without abrogating a social responsibility. It is our collective obligation as healthcare professionals to show up and to help with solutions. There is a community out there looking to us for answers.

It will not be easy. The task reminds me of the story told by one survivor of the recent avalanche at Revelstoke, British Columbia. He likened being in an avalanche to swimming. Riding the avalanche down the mountain was a struggle to keep his head above the surface, because he knew that once the snow stopped moving it would quickly turn solid and make further movement impossible.

The current situation in healthcare (with rates rising 15 percent per year) is not sustainable. The mountain is beginning to slide down around us like so many million tons of ice. We will all ride this avalanche, as there is no way to sidestep. It will take everything we've got to keep our heads above the surface — for ourselves, for our profession, for our community. When the avalanche slows down and stops — as it certainly will — the snow like so much legislation will turn to cement. We will look into open sky and breathe, or be covered up and suffocate.

So what can we do? Personally, I want to see sky and breathe air when the snow stops rumbling. So I plan to be out there this year and thereafter, swimming as hard as I can with that in mind. Being an optimist, I believe we have far more potential to influence the evolution of healthcare policy than we do over rumbling snow. How can we do that?

As SSVMS President, I would like to do several things. My first objective is to promote greater involvement by augmenting physician membership. We have already added close to 100 new members in six months. I would like to double that during the next year. It is critical for us to work towards majority involvement of the licensed physicians in our region.

Second, I want to use SSVMS to convene and catalyze intelligent discussion about community health care issues among medical and non-medical stakeholders. I plan to push our various committees to prioritize the many important issues, select the most important and work towards usable resolutions. This must involve physicians, community groups, and others with interest and expertise that can contribute toward solutions.

Third, I want to call a "code blue" on the traditional relevance of the Medical Society, and to influence physicians to think differently. Organized medicine can no longer be simply a networking infrastructure for health care delivery across a community of relatively independent practices. It needs to be resuscitated (perhaps resurrected) to fit current issues and the real-time agendas of today's practicing physicians.

Finally, I would like SSVMS to champion rational approaches to healthcare issues through frequent interchange with the media, our Chamber of Commerce, elected officials, and community groups. SSVMS should publicly support appropriate policy, and should voice coherent disapproval for what is inappropriate. If science does not support the existence of cancer clusters, for example, then SSVMS ought to be out there saying so. Perhaps people will listen to their doctors if their doctors speak up.

These are my objectives. But I cannot be successful alone. It's a big avalanche, in which each of you has a path, a struggle and something to give.

Practicing physicians — your gift is your attention. When busy clinics, access and payment issues, and demands of home and family press hard on that precious little left in your day, take the time to speak out about what works and what fails. No one else understands current practice as you do. Lend us your real-time knowledge.

Retired physicians — your gift is your maturity. You understand much better than most the perspective of lifetimes. The power in what you can give is so much more than you imagine, because your experience is magnified by the lives of others you have known. An hour of your time can make such a difference. Lend us your wisdom.

Student and resident physicians — your gift is your energy and open minds. You understand that anything is possible, and that to dream is to create. An hour of your time can excite and energize the most entrenched of your older peers. Lend us your exuberance.

Spouses, partners, friends and family — all the rest of you involved in lives and careers outside of medicine — each of you are perhaps the most important of all. You are the reality check, and know better than those of us on the front lines whether the solutions and the policies we champion will work in a real world with real people. Lend us your balance.

Think of it — real-time knowledge, the wisdom of lifetimes, exuberance and balance. Working together we can make a difference, magnifying each other's efforts to change a landscape.

It is an interesting time in health care. The storm is well underway, and the avalanche is beginning.

In change there is tremendous opportunity. I encourage you all to keep looking up at the sky, and to swim as hard as you can. I will be right there beside you.

paul.phinney@kp.org