Time for change in education

I spend most of my time thinking about how to improve a broken health care system, and how to leverage information technology to enable improved health care processes.  But, our educational system is also broken.  And, information technology can also enable improvements in education processes.

In a New York Times op-ed this week, David Brooks describes the “tsumani” of change coming to the field of higher education, as web-based distance-learning approaches are embraced by top tier universities and threaten to disrupt the traditional campus-centric approach. Although some of the respondents defended the humanism of face-to-face education, most acknowledged the need for change, and embraced the concept of leveraging the internet to enable a more effective system. I think this trend is long overdue.

I am grateful for the education that I received from the University of Notre Dame and the University of Chicago.  As years have passed, I have come to appreciate the value of that education more, not less.  But, to be honest, there is a lot of room for improvement.  Far too much of the traditional college education process takes place in large lecture halls in which a fraction of the enrolled students attend lectures and take notes for many others who don’t find it sufficiently valuable to show up.  At the front of the lecture hall is a person who was selected and promoted for his or her ability to pump out research papers to be published in journals that often have little editorial rigor, a small actual readership and questionable impact.   Too often, the lecturer was not selected or promoted for being a talented lecturer.  And, since true talent at lecturing is rare, even good local lecturers are unlikely to be as good as the top lecturers around the world.  Because many classes are large, the tests often are quite mechanical, thereby creating a system of incentives in which the students focus on mechanical learning — regurgitating a fact base, rather than developing latent talents, honing skills and acquiring insights.  Then, students participate in labs or discussion seminars led by graduate students that were not selected for their ability to lead discussions.  Furthermore, as shown in the graph below prepared by Mark Perry,  our system of higher education has been growing more and more expensive, putting it out of reach for more people.

I don’t think the problem is with the educators.  As with doctors, educators do heroic, creative things to achieve the best outcomes they can. Rather, the problem is with the system.  As taught by one of my health care heroes, Don Berwick, “every system is designed perfectly to achieve exactly the results it gets.”

I am hopeful that web-based education will disrupt this old system, driving up effectiveness and driving cost way down, thereby increasing access.   I am encouraged by the high quality level of such resources as Khan Academy, an absolutely fantastic collection of interesting free lectures taught by amazingly talented lecturers.  Schools use these lectures to turn the classroom “upside down,” pushing the lecture portion of their teaching to homework hours, leaving the in-school time for students to work together and receive individual and small group coaching from the teachers to address any remaining confusion about the subject material and provide experiences that deepen learning.

But, I think the transformation will go beyond just shifting classes from physical to virtual classrooms.  I think it might lead to a system in which many more people get involved in teaching, mentoring, and coaching, and in which people can continue their education and development throughout their lives.  Our traditional process for higher education ends quite abruptly at graduation, with ongoing contact between educational institutions and their alumni focused more on fund-raising than continuing education.  And, our approach to human resource development in the workplace tends to go through periods of fad and famine.  The fads sometimes seem to be initiated by new leaders who want to demonstrate something about their leadership style, rather than a sincere and persistent effort to develop people over time.

But, when I was  in medical school going through a general surgery rotation, the department chair repeatedly implored his students to subscribe to a few medical journals to begin to build their own libraries and get familiar with the community of people that contribute to those journals.  He wanted us to become engaged in lifelong learning and to become members of those communities.  Of course, we looked at him like he had three heads — as if we could afford to spend hundreds of dollars on journal subscriptions and spend time reading them when we had tests to study for.  But, he was right in ways I did not appreciate for years.  In my professional life, when I have had the opportunity to mentor others, I have always found it rewarding and beneficial to my own learning.  When I have had the opportunity to be mentored and coached by others, I have always valued the experience.  And, when I have taken the time to read and write about advancing the field, I have felt a satisfying sense of belonging and camaraderie within our professional community.

I look forward to an educational system that blurs the boundaries between the campus experience, professional continuing education, human resource development and professional networking.  Imagine a pre-graduation higher education process that places far more emphasis on establishing ingrained habits for lifelong learning and creating durable learning networks that can morph over time as the learner moves through different industries and grows to higher levels of responsibility and leadership. Imagine university faculty continuing to check in on their students over many years.  Imagine social networking tools that go beyond just connecting people with similar interests to creating a vehicle for mentoring and teaching, perhaps with capabilities for testing and assessment, educational and career goal setting, and  financial or non-financial rewards for faculty.

Forward looking health care organizations are already pursuing some of these changes. For example, the Henry Ford Medical Group has established new processes and web-based tools to integrate continuing education, assessment and evaluation, credentialing, and professional networking for residents, fellows and senior staff physicians, facilitating and incentivizing lifelong learning and professional development.  These developments make me hopeful that our educational system is about to dramatically improve, and that the benefits will spill over into our health care system.

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The free market is at the heart of diverse debates in health care

Wil Rutt, MD, the founder of the Center for Clinical Effectiveness and my boss during the 1990’s at Henry Ford Health System, is retired.  But, he still has an interest in the improvement of our health care system, and he still sends interesting articles to provoke thought and constructive dialog.  This week, Dr. Rutt sent two New York Times articles, asking for a response.   I found it interesting that both articles, seemingly unrelated on the surface, have in common a failure to appreciate the value of free, competitive markets in health care.

Supreme Court Decision on Health Care Reform

In the first article, Adam Liptak discusses the upcoming Supreme Court decision regarding the health care reform law, describing it as a career-defining decision for Chief Justice Roberts.  Conservative political leaders are against the law.  Many such leaders have argued against the constitutionality of the law on the grounds that the mandate that people purchase health care insurance extends the power of the federal government to regulate interstate commerce beyond the intentions of the framers of the constitution.  This debate is interesting in that it cuts across different facets of conservative thought: the libertarians, the free-marketers and the “haves.”  The libertarian-leaning side of conservative thought focuses on maximizing personal liberty by minimizing government power.  The argument against the health care reform law’s expansion of federal commerce powers is completely consistent with this aspect of conservatism.  This argument is also aligned with the interests of the “haves” (recently re-labeled the “1%” by those at the opposite end of the political spectrum).  Except perhaps for Warren Buffet, who argued in a NY Times Op Ed that tax rates should be increased for anyone with annual income over $1 million, wealthy Americans are usually not eager to foot the bill for social benefits for others, particularly not for expensive and rapidly escalating health care benefits.

But, the free-marketers seem to be taking a back seat on this issue.  Free marketers are skeptical that a monopoly provider of health care insurance services will be efficient and maximize value.  For this reason, free marketers loathe the notion of a federal government-run single payer system.  They prefer a market with multiple competing private health insurance providers, with just enough government regulation to ensure that competition is real and that consumers are properly informed and protected.   Such a competitive private market has worked well for property and casualty insurance, where the risk of loss can be assessed by the insurer almost as well as by the insured.  But, in health insurance, the insured have superior knowledge of their own health status.  Therefore, it is a widely held belief by health economists that if insurers are to be forced to offer insurance to everyone, it is necessary to have a mandate for people to purchase insurance to make a private health insurance system work.  Without such a mandate, health economists fear that too many people will wait until they know they are sick to buy insurance, forcing insurers to raise rates.  This dynamic is described as “adverse selection” and is thought to eventually lead to a death spiral where private insurers fail. According to this view, if you don’t mandate the purchase of private health insurance, you are implicitly sabotaging a free, competitive market for health insurance that can support near-universal coverage.  The only alternatives are a government monopoly, paid for with mandatory taxes, or a continuation of a broken system that fails to insure tens of millions of Americans.

It seems to me that a coalition of the libertarians and “haves” within the conservative community have overpowered the free-marketers.  Republican presidential candidates are being forced to reject the mandate as a condition of being worthy of being a “true conservative” (despite the fact that both Gingrich and Romney have supported such mandates in the past!).

Milton Friedman

Remember Milton Friedman, the Nobel laureate economist from the University of Chicago?  He used to be considered a conservative.  He was a free market conservative.  He advocated for universal tax-funded high deductible health insurance, administered by the government or through vouchers that could be used to purchase such insurance from private insurance companies.  He advocated for the elimination of Medicare and Medicaid, the elimination of tax exemption for employer-provided health insurance benefits, and for the adoption of medical savings accounts.  All of these proposals were aimed at having consumers bear the costs of non-catastrophic medical care so that free market mechanisms apply, as they already do for other necessities of life such as food and shelter.  If Dr. Friedman were alive today, he would probably not pass the current test of being a “true conservative.”   I call for the free-marketers to speak up.

America Stealing Doctors from Third World

In another New York Times article served up by Dr. Rutt, Matt McAllester describes the “brain drain” of physicians from third world countries who seek training in the U.S. and then stay in the US.  Such physicians stay because they will have access to the latest technology and they can make ten times the salary they would earn in their native countries.  The article portrays this as unethical behavior by the US that harms the third world countries.  The article does not advocate for any particular remedy.

In my opinion, it is necessary to take a broader view.  This medical brain drain problem is an undesirable side effect of a larger trend that has greatly benefited the third world.  As described in a compelling and entertaining way by Hans Rosling, the last century has been characterized by dissemination of scientific and economic innovations throughout the world which has lifted up third world countries in terms of health and economic advancement.   The free flow of capital, goods, labor and ideas across the world has been the driver of this broad advancement.  This amazing global success (with some tragic exceptions such as with the AIDS epidemic holding down Sub-Saharan Africa), has been underappreciated by those who fight against “globalization.”

In this context, should we try to protect third world countries from brain drain by constraining the existing freedom of the world market for physician services and therefore constrain opportunities for physicians from those countries?  I don’t think so.

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I agree with the protesters that the proposed SOPA/PIPA anti-piracy legislation is more bad than good

Today, a number of web sites, including the amazingly useful Wikipedia.org site, have gone black to protest proposed anti-piracy legislation making its way through the U.S. Congress.

On the one hand, the entertainment industry does face a real problem as people are so easily able to steal their product and widely distribute it to people in the US using social network and other tools based outside of the US.  So, I can see why they are trying to get as much power as they can to shut that down through any of the U.S-based parties that are involved, such as search engines, web site hosts, and credit card clearinghouses.

From their perspective, all that talk about the importance of the internet as a vehicle for freedom and political change is a bit insincere coming from parties that are just trying to make a buck knowingly casting a blind eye to the fact that their customers are deriving a big part of the value of using their services by accessing stolen content.  The entertainment industry is basically just saying that if such parties are not putting in a reasonable amount of effort to block that, they should be considered accomplices to the theft.

But, on balance, I do side with the protesters.  The definition of reasonable amount of effort can very easily become a slippery slope to requiring tiny start-ups to buy unaffordable technology and putting in an unaffordable amount of manual labor into avoiding being accused of being an accomplish to someone else’s crime.  I agree with the protesters that this could easily stifle such start-ups, which would not displease the established big entertainment players.  The entire US-based entertainment industry is just not a very big part of the overall economy, and the internet has become an indispensable part of the entrepreneurship, innovation, political discourse, and social interaction that moves society forward.  The unintended consequences of the proposed SOPA/PIPA legislation, both directly in the US and on the precedent-setting impact on laws in other countries, could be huge and are not worth squeezing a few more dollars out of one small sector of our economy.

Therefore, we should reject the SOPA and PIPA legislation, and continue to pursue more incremental efforts to thwart internet piracy.

More information at http://en.wikipedia.org/wiki/Wikipedia:SOPA_initiative/Learn_more

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Slides for Dr. Ward’s Presentation to The World Congress 2nd Annual Leadership Summit on Predictive Analytics, Boston, August 2, 2011

Click here for slides in PDF format

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