THE REVOLUTIONARY

Donald Berwick says our nation's world-class hospitals and doctors are delivering health care that is unsafe and unreliable. But his call to dismantle the system makes the medical establishment uneasy -- especially since he used to be part of it.

Author(s):  Neil Swidey  Date: January 4, 2004  Page: 10  Section: Magazine

In March of 1999, Ann Berwick completed a 28-kilometer cross-country ski race in Alaska. Three months later, she could barely walk. For Ann, an environmental lawyer almost unbounded in her love of hiking and skiing and everything outdoors - she and Don had climbed Mount Rainier together - this sudden loss of mobility was terrifying. Worse still was not knowing what was causing it or how much worse it might get.

Don used his many connections to get her the best care possible. Ann would spend about three months hospitalized in some of the nation's most respected health facilities, mainly Brigham and Women's Hospital as well as the Mayo Clinic and Spaulding Rehabilitation Hospital. Don checked out of his work at IHI to help manage his wife's care. It became clear early on that no one would be able to tell Ann much more than that she was suffering from some kind of rare autoimmune spinal-cord problem. It also became clear that all those problems with health care Don had spent the last decade complaining about were even worse than he thought.

"I was not surprised," he says, "but I was shocked."

There were medication errors. One morning, a neurologist warned that Ann shouldn't get a certain kind of drug. By that afternoon, someone had given it to her. Another medication was discontinued by her doctor on her first day of admission, but the nurses continued to bring it every night for the next two weeks. Later, her doctors decided to put her through chemotherapy to try to stop the deterioration of her condition. "Time is of the essence," her doctor told her. The first dose was given 60 hours later. She was to get a single dose of the extremely dangerous chemotherapy drug daily for five days.

On the third day, the nurse came in and hung up the intravenous bag and started to put it in. "The bag said `Number 2,' " Berwick recalls. "But it was the third dose. I was there. I had seen the others. I told the nurse. She just assumed I was wrong. If I had been 10 years old, she would have been patting me on the head, saying, `I know, I know, don't worry, honey.' I almost wanted to grab her by the lapels and say, `Listen! I know something!' " (The nurse eventually checked the record, and agreed.)

He and Ann also saw how profound the system's amnesia is. He estimates she came into contact with about 100 doctors in three months. How could she get effective care when it was painfully clear that almost none of the doctors were comparing notes?

They also saw unbelievable waste, much of which would ultimately show up on their hospital bills.

With some notable exceptions, the people they came into contact with seemed to be trying their best to provide good care. It was the system that made that impossible.

Ann's condition eventually improved, and she slowly regained her ability to walk, though she still has considerable pain. For that turnaround, the Berwicks are extremely grateful. Still, the illness remains shrouded in mystery. "If I had stayed in a lovely hotel and been waited on hand and foot for three months, maybe I would have gotten better faster," Ann says. "It would have been more pleasant, much cheaper, more fun. I had two really major medical interventions. They may have saved my life or maybe were just terribly invasive and didn't do anything. We just don't know."

What Don did come away knowing was that, if this was how the best hospitals were capable of performing, how bad must the average care be? "My wife's care made me angry - angry at very, very good people," he says.

So here's what Don Berwick did about it. With Ann's permission, he talked publicly about the experience, to the more than 3,000 people who gathered that December for the IHI's annual National Forum.

To understand the significance of this move, you must first understand how deeply private Ann is and what an extremely gifted public speaker Don is. Even now, four years later, she is still uncomfortable talking about the experience. Even now, four years later, people are still talking about the speech.

Videotaped copies have even become a standard part of some medical training programs. Azita Hamedani first saw a copy as a Yale medical school student. She is now a 30-year-old chief resident in the combined emergency-medicine program at Brigham and Women's and Massachusetts General hospitals. In November she happened to be sitting next to Berwick in the back row of a Harvard lecture hall for a talk given by France's leading authority on medical safety. Afterward, Berwick turned to Hamedani and introduced himself. Outside the hall, the dark-haired resident still looked almost star-struck as she told me, "I don't know the speaker. But to have Don Berwick there in the room means that I'm in the right place. He's a hero. This is a revolution in health care he's trying to pursue."

Just from appearance and demeanor, you'd expect the 5-foot-10 Berwick to deliver an earnest but dull PowerPoint speech. He doesn't wave his arms and never raises his voice, which has a low, occasionally rasping quality to it.

In fact, about the only way to detect his level of intensity is to look at his forehead. When he is most enraged, that large unlined swath of skin becomes grooved like a lunar landscape and his thin eyebrows just about pop off his head, like a comic-strip character's.

But there is a quiet charisma about him. He knows how to simultaneously play on the emotional and logical sides of his listeners' brains. He is also the king of metaphors. Over the years, his listeners have heard him explain health care in relation to his younger daughter's soccer team; the sinking of a Swedish warship; the Boston Red Sox; Harry Potter; NASA; the contrasting behaviors of eagles and weasels; his wimpy Ford Windstar (a dated reference since he now drives a used BMW convertible); and his left knee.

And he has a nice touch with levity. During that speech about surgery on his left knee, which he delivered last month before 4,000 people (and another 6,000 on satellite hookup), he said: "I haven't met my first grandchild yet. My wife and I want to take a trip to Nunavut someday. I want to hike in the Himalayas . . . And if you take that stuff away from me by killing me, I will be very, very upset with you."

His keynote address has become the basis by which the IHI National Forums are judged. In his measured way, he can be quite daring on the dais. In 2001, he went into character to make his point about the foolishness of doctors resisting his call for change. He alternately wore green and yellow cowboy hats to show how "Dr. Olderway" and "Dr. Newerway" would handle the same patient. Kitschy? You bet. But he managed to pull it off.

(He can occasionally be careless. That winning Socrates line he attributed to his son in his Atlanta speech actually comes from a sixth-grader whose work has been circulating on the Internet for years.)

But none of his speeches has had quite the staying power of his 1999 talk. He called it "Escape Fire," because, in addition to dealing with his wife's hospitalization, he spoke at length about a famous wildfire in Montana in 1949 in which one of the cornered firefighters lit a small "escape fire"; that blaze spread quickly uphill, leaving a burned patch behind. The firefighter hunkered down there and let the larger fire roar past him. Though his bold improvisation would change the practice of firefighting, on that day his response was too radical for any of his fellow firefighters to follow. They died, he lived.

Berwick told the crowd that health care needed no less a radical plan to get out of its current mess: "We are causing harm, and we need to stop it."

After Berwick finishes his speech at Emory University Hospital in October, Dr. Jeffrey Koplan stands up to ask him a question. Koplan, the former head of the Centers for Disease Control and now an Emory vice president, has known Berwick for 30 years.

"Don, within a few yards of your office, there's a cluster of academic hospitals. If one of them were to invite you over and say, `Take it over,' where would you start? And what would you see as the biggest obstacles?"

Berwick smiles. "My office overlooks the Brigham and the Beth Israel medical center, and I admire those places so much. The [National Institutes of Health] thinks they're great. So does the Nobel Prize Committee. They are great. But to go in and say to great places, `Let's talk defects,' it's very hard."

His response says a lot about why Berwick has had less traction in Boston than outside of it. (Berwick's collaborative model asks all hospitals to learn from each other. But as one Boston doctor says, "Can you imagine world-class Mass. General being asked to follow the lead of some hospital in Milwaukee?")

But Berwick never really answered Koplan's question. Flying back to Boston with Berwick that October night, I press him on it: "If someone offered you the keys to one of those respected hospitals, would you take them?"

"I'd better not try," he says, smiling. "It's a really hard job. You have to have many, many skills. I don't think I have them all."

In fact, Berwick knows all too well how tough the job can be. In 1998, Dr. James Reinertsen, his friend and fellow soldier in the quality-improvement movement, took over as CEO of Beth Israel Deaconess Medical Center. Berwick served as one of his references. Three years later, amid a sea of red ink and open hostility from the medical staff, Reinertsen was forced out.

No one suggests that Reinertsen's agenda for quality improvement was responsible for his overall ineffectiveness as leader of the newly merged institution, but it's a sobering lesson.

Today, Reinertsen stresses that the financial fundamentals have to be in place before you can attack quality improvement. "If you're fighting for air and water, it's kind of hard to be doing opera," he says. Reinertsen now works for Berwick as a senior faculty member of the IHI, where his focus is teaching CEOs how to improve quality in their hospitals.

To date, Berwick has been much less successful in winning converts in the corner office than on the front lines. And even some people who consider themselves Berwick fans says it's a recipe for burnout for him to ask the self-motivated doctors, nurses, and mid-level managers who are his disciples to shoulder more and more of the soul-sapping improvement work without ensuring complete buy-in from their bosses.

"It takes really significant commitment from the top to get the attitude of continuous quality improvement spread throughout an institution," says Dr. Troyen Brennan, president of the Brigham and Women's Physician Organization and author of groundbreaking studies on medical-error deaths. "And it takes a lot of effort. You have to keep pounding at it. People fatigue. But it's hard for a CEO to identify other CEOs who have used this as their means to success, who have really survived and thrived as a result of it."

David Blumenthal, director of Massachusetts General Hospital's Institute for Health Policy, says that unless the reform movement tackles the 800-pound gorilla of health care financing, "fatigue and erosion in gains" will be inevitable.

Even CEOs who buy into Berwick's message will only go so far. Dr. James Mongan, chief executive of Partners HealthCare, the parent company of Mas sa chu setts General and Brig ham and Women's hospitals, says any call to blow up the system is ultimately unworkable, because it is impossible to shut down the 24/7 health care system to rebuild it. "Nobody, not even Don, has a whistle they can blow so we can stop health care and then start it again," Mongan says. "I'm a believer that the world improves more through evolution than revolution."

A setback for the campaign to enlist more CEOs came last year with the publication of a study showing that there is currently no "business model" for quality improvement. Right now, the medical institutions that undertake improvement measures do not see any financial rewards, because either the savings show up too many years down the line or they go to another party, such as an insurance company. This is not a reality Berwick runs from. After all, he was the study's coauthor.

In fact, for someone who's staked his claim as a revolutionary, Berwick can at times be surprisingly realistic about how winnable the war might be. "Progress is just much, much slower than I thought it would be," he says. "It's so obvious to me. I just don't get why the leaders of health care don't see what I see. Sometimes I wonder, am I wrong? I'm not smarter than these people, so maybe [change is] not possible."

It's true that, for every component of his utopian vision for health care, Berwick can now point to at least one institution working with IHI that has posted stunning improvement, from Dominican Hospital in Santa Cruz, California, which has wiped out ventilator-associated pneumonia, to Dr. Gordon Moore's high-tech practice in Rochester, New York, which has wiped out waiting and inefficiency. But Berwick acknowledges that there is no system that has put it all together. "Five thousand hospitals in this country, and not one Toyota," he says. While that in cre men tal progress might have satisfied him a few years back, his wife's hospital experiences convinced him that revolution holds the only chance for sustained change. "I wonder if I'm less effective for having been radicalized," he says. "I can no longer take moderation."

But here's the irony. Any self-doubt he may experience comes at a time when Berwick is increasingly being embraced by the mainstream. The evidence is everywhere. When he recently addressed the board of the American Medical Association, for so long an old boys' collection of traditionalists, it was at the AMA's request - something that would have been unheard of just a few years ago. Even in Boston, Berwick is beginning to get more respect from the traditional power centers. Mongan, who took over as CEO of Partners a year ago, has made quality improvement a priority and plans to spend more than $30 million over five years on technology designed to improve patient safety. Mongan gave Berwick a copy of his improvement plan in draft form and asked for his input.

The fact is, Berwick's proselytizing has produced so much more awareness about safety and quality problems in hospitals that most health care leaders no longer argue with his diagnosis, even if many still take issue with his prescription. (The areas of medicine that have adopted systems improvement, notably anesthesiology, have made huge leaps in safety.) Brigham's Troy Brennan puts it this way: "The changes are small, but slowly people's attitudes are changing. That's something that should be very gratifying to Don."

And at his core, Berwick is an optimist, so the bouts of self-doubt seldom last long. At an IHI staff meeting in November, a staffer named Jose says he worries about falling behind on his projects when they all decamp for the IHI's annual weeklong National Forum. Berwick immediately starts furiously scribbling on a piece of scrap paper.

A minute later, Berwick jumps up. He rattles off a series of calculations he had just made, taking into account statistics on medical errors, the numbers of people who would be in the audience for the conference, and the success rates so far from IHI error-reduction programs. Then he offers his conclusion, which puts to rest any concerns Jose may have had. "Every single person in this room," Berwick says, "is going to save five lives during the forum."