A Conversation with Dr. Al Mulley Jr.

Conversations with Leaders in the Field of Patient-Centered Care

One of the ways Picker Institute supports patient-centered care is by recognizing significant contributions to achieving patient-centered care nationwide. “Conversations with Leaders in the Field of Patient-Centered Care” is a regular feature that highlights these contributions. This Conversation is with Dr. Al Mulley Jr., named the director of the Dartmouth Center for Health Care Delivery Science in September 2010 and a winner, with his colleague Dr. John Wennberg, of the Picker Award for Lifetime Achievement in 2005.

Dr. Al Mulley is the director of the Dartmouth Center for Healthcare Delivery Science. Before assuming that position in November 2010, he was the founding Chief of the General Medicine Division and Director of the Medical Practices Evaluation Center at Massachusetts General Hospital and Associate Professor of Medicine and Associate Professor of Health Policy at Harvard Medical School. He graduated from Dartmouth College and was awarded a doctorate in medicine and a master’s in public policy from Harvard before training in internal medicine at Mass General.

Dr. Mulley’s research has focused on the use of decision theory and outcomes to distinguish between warranted and unwarranted variations in clinical practice. This work has led to development of research instruments and approaches, including shared decision-making programs, to support clinicians and patients in their decision-making roles, and to catalyze both learning collaboratives and clinical trials. These approaches have been shown to decrease utilization of high-cost medical and surgical interventions while improving measures of decision quality, including stronger associations between patients’ personal preferences for health outcomes and the care that they receive.

Dr. Mulley’s work to improve the quality of healthcare decision-making has influenced the agendas of many public and private organizations engaged in clinical care as well as medical research and education. He was a founding director of the Foundation for Informed Medical Decision-Making and continues to serve as senior clinical advisor. He has also served on multiple committees of the Institute of Medicine, of professional societies and as a consultant and visiting professor to government agencies, healthcare organizations, and academic medical centers in North America, Europe and Asia.

A Conversation with Dr. Al Mulley Jr.

You’ve been in your new post for just about four months now, and you must feel a little like a kid in a candy store. Are you getting a grasp of all the possibilities that await, and which ones are you most excited about?

There were indeed many possibilities when I arrived on Nov. 15, 2010—multiple projects associated with the center in five domains: education, implementation, research, collaboration and public engagement—and within each of those categories was a handful of specific projects.

In education, for example, we were launching a new Master of Science in Healthcare Delivery; we were going to look closely at a new approach linking baccalaureate education with undergraduate medical education in an AB/MD design; and we were exploring ways to significantly, if not radically, reform undergraduate medical education itself to include the elements of the science of healthcare delivery.

We saw lots of potential synergy in all these areas. For instance, the AB/MD design would influence undergraduate medical education. We wanted it to, if you will, inoculate future medical students against the hidden curriculum they would run into in medical school.

Certainly developing the content and curriculum for the Master of Science in Healthcare Delivery would influence the undergraduate medical curriculum. And there were so many opportunities for postgraduate training in medicine, opportunities in research and collaboration.
When I joined the leadership team and had a conversation with other people about priorities, what came out of that was a recognition of the need to take that long list and turn it into a narrative about the center’s focus. In fact, I spent the first couple of months doing a lot of listening to conversations about the many assets here at Dartmouth and how they could be brought to bear in developing a solution set for healthcare— and understanding that everyone here was radically committed to changing the conversation about healthcare.

In an interview you did with Dartmouth Now right after your appointment was announced, you mentioned that the new center will bring together the undergraduate and graduate schools of medicine, business and engineering, as well as arts and sciences, to generate profound and lasting changes in healthcare. With this degree of innovation, do you envision a new field of study that brings all these elements together? a new degree? What does each discipline bring to the whole?

The Master of Science in Healthcare Delivery is an 18-month program. It will start in early July with 50 people in the first class, and we’ll be conferring the first 50 degrees in December of 2012. I’m going to teach, [Dartmouth president] Jim Yong Kim is going to teach and many of the faculty from the Dartmouth Institute will teach. The interesting thing is that when this center was announced, no one said Why Dartmouth? and that’s because of the preexisting strength, most recognized in the work of the Dartmouth Institute: Jack Wennberg, Paul Batalden, Elliott Fisher, Milton Weinstein, Gil Welch and many others.

Dartmouth has one of the leading business schools in the world, Tuck, so we’ll have a stunning business school faculty working very closely with the Dartmouth Institute faculty. In fact, every other Wednesday they hold faculty integration seminars, learning from each other about frameworks and vocabulary and thinking about how operations management applies to healthcare, thinking about how a value compass may or may not be the same thing as a balanced scorecard. It’s going to be a very unique and exciting program, and I think we will be training a disproportionate number of future leaders in healthcare delivery.

The investments that Dartmouth will be making through this center will be models, methods and metrics to apply the discipline of science to healthcare delivery—but also new ways of capturing experiential knowledge, new ways of developing delivery and disseminating business school case studies, which were originally borrowed from medical CPCs [Clinicopathologic Conferences]. So there’s this historical connection between healthcare and business education around experiential teaching through case studies.

We’re going to really push that into the digital interactive social media age, and that will help us very much to understand how the discipline of science can lead to innovative redesign appropriate to different contexts. Because this master of science program is residential distance-learning blended education, with six weeks on campus and the rest of the 18 months at home, and potentially with continuing employment, it’s only appropriate that we invest a great deal in technology for teaching in new ways and for advancing our understanding of experiential learning. One of the first principles for healthcare delivery science will certainly be to always—always!— design as much to learn as to deliver. And that applies as much to education as it does to healthcare, so to everything we’re doing in this new master’s program and the other elements of the center we are bringing a good deal of humility and designing to learn by delivering the courses.

What kind of student do you think the program will attract? What will students in this program be studying five years from now?

I think this curriculum will attract people from one end of the pipeline to the other. When I went into medicine, there was a very strong cohort of individuals in medical school classes across the country who were drawn to general medicine and primary care because it was seen as a perceived need, and there was a great deal of excitement about the interdisciplinary nature and about being comfortable with uncertainty and judgment. There was a recognition of the negative unintended consequences of specialization, and there was sort of an arc to that history that continued through the ’70s and into the ’80s. It certainly wasn’t helped with managed care and the way in which primary care was viewed during the rejection of managed care by many people. I think the same cohort of medical students and residents is there. They’re often drawn to global healthcare now by the same kind of idealism that brought their predecessors into primary care. And the interesting thing about healthcare delivery science is that it is about universal principles that are relevant across the range of all the nations.

Studying five years from now? The liberal arts, hopefully at a university that has robust offerings that get you to think hard about resources and the allocation of resources—that would surely be economics—and about context and the way people relate to one another—that might be sociology. But there’d also be an incredibly important role for the humanities because so much of healthcare and so much of its inefficiency is due— no matter how good the intention, and I’m going to assume good intentions from every party—to the difficulty of keeping the interests of agents, people who are often in a position to make decisions, and principals, people who live with the consequences of those decisions, well aligned, not necessarily because of financial incentives but because of other dysfunctions in the system

It’s difficult to keep them aligned because the communication about what people care about is difficult and time-consuming. So there’s an incredibly important role for narrative, for drama, for literature to prepare people to deal with resistance to change in thinking about their roles and relationships to one another in giving and receiving healthcare.

How would you define the science of healthcare delivery?

That’s the question. The temptation is to say that it is medicine plus public health plus systems engineering and management sciences and economics and sociology and anthropology and psychology.

But a better way to think about it is to ask yourself what science is about. It’s about a very disciplined collection of data used, usually, to falsify a hypothesis that came from a model or a theory. Your effort is to falsify the hypothesis so that if you can’t falsify the hypothesis, you now know something about the relationship between variables. That’s how science advances knowledge and, interestingly, it hasn’t been applied very much to questions of healthcare delivery.

Think about the fact that there are 80 million people over the age of 20 with high blood pressure in the United States and that their regimens are often changed because their blood pressure is too well controlled or is not controlled enough. A patient is just as likely to be told to come back for a recheck in two weeks as in two months or two years because no one has ever applied the discipline of science to the question of what the right interval is. If you recognize that there are 80 million such people, that’s a pretty expensive piece of ignorance in terms of inconvenience, the dollar cost, etc.

I think the science of healthcare delivery will be about applying the discipline of science to questions of delivery. But if we stop there, we would risk falling into the reductionist trap that much of medicine has fallen into in the past. If you think that everything that’s knowable or important in making decisions or executing against goals can be reduced to the elemental variables that you can easily study and control, then you’re leaving out a lot of what might be referred to as experiential, or tacit, knowledge—the kind of knowledge that is related to context.

So the discipline of science is important, but it’s not enough. You need to also bring the discernment that often comes from experience across different contexts. Backing up a little bit, the story that brings together so many of the opportunities here is that healthcare is too complex because of the uncertainty of outcomes and because of the disagreement among people about how they feel about outcomes. So standardize what should be standardized, but honor the differences that make illness, its treatment and its outcomes have different meanings for different individuals.

All of that is so complex that you need the very best thinkers across disciplines, intentionally connected to the very best doers across contexts, to try to find innovative solutions to problems. If you don’t have a portfolio of contexts, the best ideas to redesign delivery to make care more effective and efficient will succeed in some contexts but fail in others, so that if you don’t have the variable contexts in which to work you’ll discard a lot of good ideas. Of course, it is also very important to be able to communicate effectively in order to reduce the resistance to change.

You organized an international conference in May around a discussion of what has been called “the triple aim”: better care, better health, lower costs. In view of the massive problems that plague our healthcare system, how confident are you that this goal can be realized? What do you think President Obama’s healthcare reform has contributed toward a solution?

I’m quite optimistic that the goal can be realized. It won’t be easy. It will take the best thinkers, the best doers and the best communicators, and it will take building new models, new methods and new metrics to apply the discipline of science rapidly to redesigned ways of delivering care. Make no assumptions about the next new redesign being more effective than the old way, but move very quickly to understand whether or not it does constitute an improvement that is going to require new models, methods and metrics. Randomized trials won’t work all the time. But there are community experimental methods and non-experimental methods to determine causation and simulation models that can inform hypotheses, so all of that has to happen in order to change the conversation about healthcare delivery.

Again, I wouldn’t leave out the importance of recognizing that some of these redesigns are going to work in some contexts defined by the way in which care is organized and paid for, and by the level of resources available in one community as opposed to another.

I think that one very positive result of healthcare reform legislation—as controversial and politicized as it has been—is that it does change the conversation. In other words, historically, the way that some stakeholders could reduce their costs of healthcare was to shift costs by changing levels of coverage, or the number of individuals who were covered. Eliminating that mechanism to reduce costs from one perspective forces us to pay much more attention to the question of efficiency and effectiveness.

My own belief is that part of the politicization has been a failure to recognize the advantages and disadvantages of planning a healthcare economy by determining capacity based on some expert opinion on the one hand, which has lots of flaws but also some advantages, versus trying to make the market work so that people can reveal their wants and needs in the choices they make. Individual choices that reflect personal wants and needs is the way a market leads to efficiency, but there are also ways in which markets fail when information is very imperfect or asymmetrical, and when it’s difficult to adjust capacity because it’s difficult to leave the market once you’ve invested to get in.

Look at planned single-payer taxpayer-paid healthcare economies like the National Health Service in the UK, which has advantages and disadvantages, and at a healthcare economy like ours that is much more dependent upon the efficiency of the market. Both have strengths as well as profound weaknesses, but I think you can move pretty quickly to develop some new models and new designs that would produce better health through better care at lower cost.

This is part of the reason for the importance of having the best doers and thinkers working closely with the best communicators across media and constituencies. I believe a major source of the resistance to change in healthcare is that all parties—doctors and other health professionals, patients and the public and policymakers and payers— have an interest in believing that science mediated and managed by trustworthy health professionals can give you the right answer, well executed, time and again despite all the evidence to suggest inefficiency and overuse, misuse and under use, the safety problems.

That evidence is pretty overwhelming, and yet thinking about how long ago To Err Is Human [2000; the Committee on Quality of Health Care in America, Institute of Medicine, Linda T. Kohn and Janet M. Corrigan] and Crossing the Quality Chasm [2001; the Committee on Quality of Health Care in America, Institute of Medicine] were published, it’s rather astounding how little progress we’ve made.

I think that the Dartmouth Center is reaching out to engage people, all of whom agree that care needs to be more coordinated and safer for patients, and more efficient. There’s not a political argument about that. I don’t know of any serious student of healthcare who believes that the status quo is satisfactory. There is so much that we agree on that the politicization is unfortunate, but real. What I’m pointing out is just that we need to go deeper in the conversation about health and healthcare to know why we seem to resist change as much as we do.

The goal of innovation and redesign of healthcare should be to make it more effective and more efficient in meeting the needs of patients, and nothing less, and the wants of patients, and nothing more. That’s a very, very difficult task. You really do need to go very deep into patient-centeredness. It can’t be a phrase or a casual commitment, and it’s difficult. Doctors and other health professionals have what has been called very sticky information to get across to patients about options, about outcomes, which are almost always uncertain and occur spread out over time. So that’s a very difficult communication task.

And patients have equally sticky information about how they feel about those treatment options, how they feel about outcomes and health states they are living with now and how they feel about possible future health states. They have to imagine accurately something they have never experienced in order to make a good decision now. They also have to communicate about whether they are inclined to live for the moment or live for the future, which has a profound effect on decisions about prevention screening, particularly when there are long lags between the up-front costs and the benefits, which may come decades or more in the future.

You don’t have to impugn anyone’s intentions in order say that the principle task in healthcare delivery design should be to keep it patient-centered. Whether or not it is appropriate to tell someone she or he is at risk for Alzheimers is a very good example of care that is standardized when it is appropriate and personalized when it is appropriate.

One of the phrases that I’ve come to use recently is that if all variation in medicine were bad, it would be easy: You’d just say, No variation. But the difficulty is that there is bad variation when it reflects collective professional ignorance because we haven’t done the research, and when it reflects the personal ignorance of a particular health professional who isn’t aware of the research or hasn’t interpreted it correctly. And then there’s left-over uncertainty, no matter how much research is done or how well it’s been managed and delivered. All of that needs to be reduced as much as possible—but then there all the good variations.

If I feel different from my neighbor about trade-offs between improvement in urinary function and decrease in sexual function, if you feel different from your neighbor about the prospect of living without a breast or having cancer come back in a breast you chose to keep– those are disagreements between patients that need to be elicited, understood and honored. Often what happens, unfortunately, is that disagreements about what is important and what matters are between doctor and patient, and they’re not recognized because the conversation doesn’t go there.

You were a Picker Award for Excellence® winner in 2005 with your colleague, Jack Wennberg, for lifetime achievement. Your work at the Foundation for Informed Medical Decision-Making, which you and Dr. Wennberg cofounded, was cited in that award, and your commitment to patient-centeredness was manifest in that project. How much progress do you think has been made in the field since then?

Patient-centered is hard. And as we know now at the Foundation for Informed Decision Making, from more than 80 trials, when you do try to make care more patient-centered by focusing on both the knowledge and patient preferences in what has been called shared decision-making, you often, if not always, reduce the amount of care delivered by improving the patient’s knowledge and increasing the relationship between what they say they care about and the care they get.

Now shared decision-making is in healthcare legislation and a new Cochrane Review, updated from 55 to more than 80 trials, demonstrates the positive effects of shared decision-making. The interesting question is why this is so difficult in practice, and why, with more than 80 trials showing improvement in patient knowledge and other effects that everyone would agree are desirable, it is so difficult to get doctors, patients and policymakers to make it happen. That’s where I would go back to my earlier comment about everyone having a stake in believing that science mediated by trustworthy clinicians gives you the right answer, well executed. For health professionals this is the source of their autonomy as well as their authority, their income and their status in society.

For patients, that belief absolves them of feeling responsible for decisions that very often lead to bad outcomes, and bad outcomes feel worse if you feel responsible for the decision. And policymakers would just as soon be absolved of the responsibility for making decisions that could feel like withholding something that people feel morally entitled to. That’s where you get into the usually uninformed debates about rationing and death panels and that sort of thing. So, as I said, health professionals, patients and policymakers all have a stake in believing—despite all of the evidence to the contrary— that science mediated by trustworthy clinicians will give you the right answer, well executed.

Can you talk a little about your work in Honduras? Do you see progress, or are you holding the line? Is the need greater? Do you have the resources to meet it?

My work in Honduras is very modest. I went every year for 10 years with a team of young people, who usually did construction projects related to public health and social capital within the communities, and five or six other health professionals to deliver primary care in the same five mountain villages. We also made sure that there was infrastructure that would provide continued care when we weren’t there by working with the local communities as well as the local church. The Honduran doctors we worked with were part of the same communities when we weren’t there. I learned a great deal about the importance of partnerships based on mutual respect and working hard at minimizing any sense of asymmetry of influence in situations where the resources available to one partner were very different from those available to another. We’re going back this year—we had a year off because of the political situation in Honduras—but whether I will be able to go this year depends on my commitments at the center. But I will be going back in the future.