Dr. Halsted Holman discusses why medical clinics have barely changed in decades and what leadership is needed to adopt the chronic care model. He examines the obstacles to implementing these changes in medical schools and clinical practice.
If you look today, for example, at the clinics, at our hospital, and at many, many other medical school hospitals, the character of the clinics hasn't changed. Now, that's not true where there has been very intensive technology development, such as in cancer. But if you look at general internal medicine, family medicine, the usual specialties of endocrinology and infectious disease and so on, the way the clinics are run and the role of the patients and the doctors hasn't really changed in the last 30 to 50 years. So many of the ingredients that go for good care of chronic disease, such as teaching your patients how to cope more effectively with the range of problems their disease creates, maintaining continuity of care for those patients, assuring integration of the different services that are given to the patients, none of these things really happen or can even happen because of the way in which we structure our clinics. So in a nutshell, what the answer to your question is is a leadership failure. And the leadership failure, in my view, is the result of a focus of attention on only a part of the problem. Lord knows, we do need more understanding in biology, but simultaneously we need a better understanding of how we apply whatever we know to the individual patients and to groups of patients with particular diagnosis. So I really fault the leadership very substantially now. From time to time, leaders have appeared who really understood this issue and wanted to induce change. And there they've been frequently, almost always, usually at any rate frustrated by the fact that it's very hard to change a large bureaucratic organization like a medical school. People are used to doing things in one way and reluctant to change. Now, I know I'm talking a bit too long here, but I'll add one feature. When you do change your practice along the lines of the chronic care model of practice, and become a partner with your patient and spend time helping that patient to cope with whatever the consequences are of the disease. And if you can develop your office so that you have an element of team care, because good chronic care is a large task, and if you have a well developed office along the lines of the chronic care model prescription or some others, you find that the practice goes much better so that the patients, if you're measuring outcomes, are better than you had previously accomplished, the patients are more satisfied, your practicing experience is more rewarding, and your staff feels themselves much more involved in the active care of the patients. So that we do know that when you make the transformation along the lines of the chronic care model, you will begin to experience outcomes that are much better than conventional practice usually yields. Now, we haven't been able to do that in the medical schools. There are almost no medical schools that have adopted their clinical training in that way. So we've moved, so to speak, off campus into the community, which is where the physicians and the patients and sometimes the administrations are much more responsive to this need to adapt medical practice to the prevalence of chronic disease amongst the patients.
