The ostrich and the wolf: the dangers of complacency

David J. Leffell, MD
CEO of Yale Medical Group

Letter from the CEO

Yale Medical Group CEO News is a newsletter from David J. Leffell, MD, deputy dean for clinical affairs for the Yale School of Medicine. He covers topics of interest to the practicing physicians. Write to Dr. Leffell at

For 30 years, the Rubik’s cube of health care in America has slowly twisted and turned, and it bears the indelible fingerprints of politicians, physicians, academics, hospital administrators, businessmen and others. Most of all, though, the cost of health care has grown to an unsustainable size.

For those of us in the trenches—the doctors, nurses and staff that provide the finest medical care available anywhere in the world, the debate about health care reform is both dizzying and worrisome. We live in a community where there is a consensus about the need for universal access and coverage: What good is the best medical care if a large percentage of the population cannot benefit from it?

Still, the complexity and enormity of the problems make them challenging to interpret and even harder to translate into our daily lives. As medical professionals we are focused on making the correct diagnosis, treating the illness and caring for our patient, not on defining, let alone parsing, the nuances of change and reform. Some of us think that is someone else's job.

The mainstream media write extensively about changes in the aspirations and status of physicians, and medical journals like the New England Journal of Medicine have increasingly become a platform for advocating specific health care policy agendas. Despite the billions of bytes that have been generated on this issue, we, as physicians, are defined by our innate optimism and continue to go to work every day, full of hope—hope that the changes that are afoot will not harm our patients and our own survival.

Unfortunately, a key strategy for many optimists is learned from that large, odd-looking flightless bird: When it comes to the “Health Care Evolution” our heads, as physicians, are firmly and securely planted in the sand.

Why are our heads in the sand?

There are a few reasons why we do not feel at risk personally and professionally as changes in the health care delivery system incrementally, but persistently deconstruct the current model, and methodically, if slowly, drive erection of a new framework.

First, many of us chose to practice in the academic environment because of the opportunity to care for patients, as well as teach and conduct research. In a sense we have diversified our professional portfolio, and some may feel that diversity insulates us from the changes that are afoot. One of the greatest ironies of health care reform, and incontrovertible evidence that the change is real, is the increasing number of private practice doctors around the nation who are seeking to become employed physicians. Indeed, even more ironic (and to be fair, flattering) is the number of physicians in our community who are now seeking to join Yale Medical Group. There is a sense that the future economics and the new model of health care delivery will be unsustainable for private practice doctors.

A second reason why we at Yale have been slow to acknowledge and respond to change is “Wolf(f)'s Law.” I know orthodontists and orthopedists have one thought in mind, but the Wolf's Law I am referring to relates to the boy who cried wolf so many times, no one believed him when the wolf was finally at the door.

The wolf is at the door

Thirty years ago, as I was applying to medical school, a faculty member in the Department of Medicine tried to warn me that the future held nothing but disaster for doctors: The government was going to socialize medicine! So the notion that health care reform is coming is not new, and precisely because of its tardiness, the many false starts, the effectiveness of powerful special interests such as the managed care industry, we have had the sense that the status quo would prevail. \

“That was a close one,” we have thought as a new adverse regulation, law or ruling is defeated, and we survive for another day. The days of “close ones” appear to be over. We can say it in a dozen languages, but, however we say it, the financial unsustainability of the current model is relentlessly driving health care reform, including major changes in the way we will practice medicine. The wolf is at the door.

The problem with the traditional passive strategy of dealing with change is that it depends exclusively on luck, and our luck is running out. While the health insurance reform law that was passed last year is complex, perhaps overly so, and includes aspirational programs like accountable care organizations that may prove challenging to implement, the law is the law and changes are happening. The nature of social change is that it is almost never radical. Aside from declarations of war and disaster relief, society tends to move slowly for many good reasons.

Society progresses, in many cases, from a grand idea, but in practice it proceeds through innumerable small, almost imperceptible steps. In the case of health care reform the end result may not be that which is strictly defined in the current legislation.  It may not even be specifically that for which the administration in Washington yearns. But the legislation does advance reform of our health care delivery system. Like an ocean liner, once the turning has begun it is hard to stop and change course.

New law is a blueprint

In this sense the new law is a blueprint, and the foundation is being laid with components like electronic medical record regulations, quality reporting measures, closer hospital monitoring, extension of the dependent insured age to 26 and many other rules. Each of these elements may not be in itself significant, but collectively they represent the nascent plan.

Nobody likes uncertainty. Financial markets abhor it. Diagnosticians fret over it. For some it is a noxious stimulus and they become paralyzed, like the subjects in Martin Seligman's experiments on learned helplessness. But the uncertainty of the future is not a reason to avoid it.  In fact, it is precisely because we do not know the steady state of the emerging health care system that we need to be instrumental in creating a new business model for care delivery that is strategic, efficient and nimble.

Most importantly, it must seek to eliminate the waste intrinsic in the status quo. Under our current clinical practice framework at Yale, we are a perfect setup for whiplash when health care reform comes to critical implementation. We are an expensive provider (albeit for some good reasons) and we are in the crosshairs of both government and non-government payers. Building on the tremendous work of faculty, staff and administrators over the past decade that transformed Yale Medical Group into a very large, recognizable group practice, we now need to evaluate our points of risk and areas of opportunity.

We would not even be able to talk about crafting a better mousetrap at this juncture were it not for our close working relationship with Yale-New Haven Hospital.

I have served in leadership roles in the practice since 1996, and in the past several years, the superb collaboration with the hospital has never been better. It has allowed us to jointly achieve critical strategic goals. Still, we have a complex relationship with the hospital, as we do within our own school. Departments still function as independent entities, and our funds flow model does not allow us to properly support clinical programs and services that are mission critical, but which on their own are not financially viable.  

We have established nationally recognized practice standards, but they are not enforced in our own practices because there is no rational structure for management. Some practices are open at 8 a.m; in others, doctors don’t see patients until 10 a.m. How long would Nordstrom survive if its many departments opened for business at different hours?  “Oh, I guess I’ll just come back next week to get my socks, but I am sure glad that I could get that new BHA-free water bottle in kitchenwares.”

It is time for us to aggressively address the programmatic, quality and financial status and structure of our practice. We have progressed as far as we can under the current model. If we think the boy is only crying wolf, or keep our heads in the sand, we will fall further behind and ultimately run the risk of failing miserably. None of this change will be comfortable or pleasant, but the alternative will be much worse.

Yale Medical Group is well positioned for change

Fortunately, during the past decade, Yale Medical Group has taken many steps that have placed us in a strong position to achieve successful change. We have:

  • worked to create an identity for the practice and the faculty who work in it that will help define our value in the market
  • selected and are now implementing a state-of-the-art electronic medical record in partnership with the Yale New Haven Health System
  • developed a business infrastructure in revenue cycle management that is one of the best in the country
  • established a strong relationship with the community physicians through our participation in the Connecticut State Medical Society
  • enhanced our  relationship with the hospital and health system through the establishment of joint leadership positions and daily collaboration so that we function as true partners

Most importantly, I believe our faculty and staff are among the best in the country!

Over the coming months, we will communicate in greater detail about steps that the hospital and school are taking together to strengthen the practice and ensure that we are competitive. You have a right to expect leadership to be clear thinking, smart, committed and effective as we lead all of us through the storm. I'll see you on the other side!