Evidence, Effectiveness and Efficiency in Health Care

What if Hippocrates, instead of saying that doctors must ‘do no harm’ to their patients, had said that they must only provide treatments known to work? Evidence-based policy making has been around for centuries – think of Roman engineering – but we think of it as a relatively modern concept. Medicine has progressed through trial and error, and there have been some spectacular, and serendipitous successes, but the ‘art’ of the physician and surgeon has been as important as the ‘science’ behind some of their practices.

While I’ve been here I’ve collected new research material for a book on the history of convalescence and lengths of hospital stays. I’m fascinated by the UK/US comparisons, and wrote an initial overview chapter in my co-edited book on hospital theory and practice in 2013. In the 1940s and 1950s there was trans-Atlantic sniping between surgeons, with the British suggesting that the Americans were unnecessarily risk-taking in their policy of ‘early ambulation’ after surgery. But both nations have been at the cutting edge (sorry) of reducing the length of stay for routine surgical procedures such as hernia repairs, hysterectomies and hip replacements.

It is impossible to understand the reductions in length of stay (from over three weeks for hip replacements in the 1950s to 24 hours now in some places) without considering how hospital medicine is funded. Although the US and UK health care systems have very different funding structures, they share similar historical concerns with the cost of care, and during the second half of the twentieth century have developed a number of techniques for assessing efficiency and effectiveness.

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The old surgical theatre, now used for lectures

Early in my visit I spent a morning with Dr John Stoekle, who in the 1950s pioneered the US version of hospital-based primary health care centres at the Massachusetts General Hospital here in Boston. He’s now in his 90s, but visits his office in the MGH every week, and is a wonderful source of oral history on how US hospitals have changed in response to rising costs of medical care, and the concept of the ‘ambulatory hospital’. He took me to see the ‘Ether Dome’ at the top of the old building (the dome being needed for light for surgery before the introduction of electricity). It was here on 16 October 1846 that a group of Boston doctors and dentists undertook the first successful surgery using ether as an anaesthetic. The MGH is duly proud of its role in medical history, and the surgical theatre is still used daily for grand rounds.

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Ernest Codman’s gravestone

On a trip to Mount Auburn, an amazing 175 acre landscaped cemetery in Cambridge, we came across lots of other worthy Boston medical pioneers. Some, such as Helen Taussig (1898-1986) the cardiologist who developed an effective surgical technique to treat ‘blue baby syndrome’, are well-known. But J spotted another character, not on the official cemetery guide map (look it up http://www.mountauburn.org) who deserves to be better known for his role in developing evidence-based medicine. Ernest Codman (1869-1940) was one of the first clinicians to routinely follow-up the outcome of his patients after they were discharged from hospital. But his colleagues at the MGH in the early twentieth century thought that this a step too far, and he was barred from working at the hospital. His gravestone is unduly pessimistic: by the 1960s health services were beginning to embrace more enthusiastically ‘evidence-based medicine’. I returned to Yale last week to continue working on the archived papers of key individuals involved in reforming hospital management, including John D Thompson who pioneered the Diagnosis-Related Group [DRG] in the late 1960s, and Milton Roemer who demonstrated that the more beds a hospital has, the more patients there will be to fill them.

I’m trying to wind-up my research here now. We spent the ‘Independence Day’ weekend in New York (which included a walking tour with Dan Fox, who naturally had lots of medical history related anecdotes). I have a last-minute rush to look at archives in the wonderful Countway Medical Library, which I will be very sad to leave, and maybe a final trip to the North End of Boston for more stuffed clams and ricotta cannoli…

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Archives and Outings

Each of my weeks here has been different – some heavily library-based, others spent more in archives, or doing oral history interviews. One of the things I love most about my job is this variety, and of course the contact with people – students, academics, and an important group – archivists – who hold the key (literally) to the materials I need for my research.

Work-life balance is important too. It is easy on research trips to get completely overwhelmed by the project. I am fortunate that J joined me in May, taking an unpaid sabbatical from the Royal Liverpool University Hospital to spend time observing pathologists at the Brigham and Women’s Hospital, and to do a head and neck pathology training course. Now he’s free to go to the baseball and distract me with ideas for road trips (we’ve had a great long weekend in Maine, New Hampshire and Vermont, which included stopping for coffee at THE Bretton Woods).

Bretton Woods New Hampshire

Bretton Woods New Hampshire

But J’s also brilliant at spotting things I would normally miss on the music scene. Last Thursday we’d planned to go to the Boston Symphony, but that morning he heard that Pixies would be playing an impromptu gig for 300 people to mark the closing of the legendary TT at the Bears club. It was an amazing gig in a wonderful venue. Music often features in my teaching. ‘Fever’ works well for the Rise and Fall of Infectious Diseases lecture for the first year medics (and HIST 239): whether I choose the Elvis or The Cramps version depends on how I feel on the day. ‘St James’ Infirmary Blues’ (White Stripes) livens up the Uses and Abuses of the Human Cadaver lecture, or ‘End Credits’ (Chase and Status) – nice link to William Harvey’s theory on the circulation of blood.

But back to the work…last week I had some fascinating meetings, including Richard Zeckhauser, the chap who coined the term QALY (quality-adjusted life year) in 1976, and Nancy Krieger, a social epidemiologist and historian whose work I have admired for many years. One of the main reasons for being here in the US for three months is to work in archives relating to the development of twentieth century health services, and last week I spent time planning my next set of visits. Records and papers held in archives are unique and despite some digitisation projects, scholars usually have to travel to the sites where they are held: they cannot be ordered on inter-library loan. Luckily digital cameras can now be used in archives (it used to be just pencils and paper) – and my working strategy is to photograph large quantities of papers and then read them back at my desk.

Milton Roemer's papers in the Yale archives

Milton Roemer’s papers in the Yale archives

When I wrote the history of the role of the Chief Medical Officer with Sir Liam Donaldson I spent a lot of time working in the National Archives at Kew in London, following the 18 CMOs who have held the post (since Sir John Simon was appointed in 1855) through the official papers. My next project focused on Brian Abel-Smith (1926-1996). He was one of the first expert advisers – in the UK and to the WHO and more than 30 developing countries – on health and social welfare policy.

All historians (I hope it’s not just me) get excited on archive visits, when opening a new box of papers. Some of the cataloguing is now amazingly detailed (thanks in part to expert training schemes such as the Masters in Archives and Records Management course taught at Liverpool) and the box contents match the finding aids. However with very large archives, especially of personal papers, the outline information can be brief: ‘Correspondence A-C’, for example. One has to request boxes in the hope that some of the content will be relevant. I think historians (or maybe it really is just me) are at heart nosey people. We can overcome any initial queasiness about looking at personal papers in the pursuit of developing more robust histories. OK, most of these people have chosen to deposit their papers in archives; they may even have ‘cleaned’ them to remove anything they would not want made public. Other sets of papers, such as those donated by relatives, may contain material that has the potential to reveal other people’s personal lives. Medical records containing patient information are automatically closed to public access for 100 years; general correspondence files rarely have such controls. There are ethical issues around historical research, just as there are for medical research.

Brian Abel-Smith deposited 183 boxes of his personal and professional papers at the London School of Economics shortly before he died. When I was invited to write his biography I initially refused, on the grounds that I am a historian, not a biographer. But I agreed to go and do a sample of the archive boxes, and it was the amazing diversity and quality of the papers that convinced me I could write a different, individual perspective on the development of health and social welfare in the second half of the twentieth century – and a global one too, given Abel-Smith’s enormous range of activities. What I had not initially, naively, expected was to have to analyse his personal life, and how his homosexuality shaped his career choices. He was a very private person throughout his working life, choosing only to publicly acknowledge John Sarbutt, his partner of over 30 years, at his retirement party. Yet he chose to leave items in the papers he deposited at the LSE archives that can only be interpreted, I think, as his wish to show the future historian/biographer aspects of his life that he could not reveal while alive. I had to check carefully that I did not unwittingly ‘out’ anyone by the way in which I wrote about them in Brian’s biography.

Brian Abel-Smith and his dog Nicky

Brian Abel-Smith and his dog Nicky

Boston Pride

I thought of Brian and John last Saturday, when J and I watched the Boston Pride parade pass the apartment – many of the marchers had their dogs with them, some in fabulous decorations. It took nearly two hours for all the marching bands, floats, and people to pass along the route. I wondered if Brian would have felt comfortable participating if he were alive now, with his dog Nicky.

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Apartment Life

Planning academic trips used to be more of a gamble, before the revelations of internet reviews, and Google Street View. Some of the more unusual places I have stayed include a Salvation Army hostel in Geneva and the nurses’ accommodation block at a Belfast hospital. For longer trips it is more practical to rent a room or an apartment. When I knew I would be here in Boston for three months I explored http://www.sabbaticalhomes.com. After some digression (there was a fabulous house in the south of France…), I found an apartment in the South End district – convenient for getting to Harvard campus, for the Amtrack station, and for some great grocery stores and cafes. I haven’t lived in a big city centre (or without a garden) since I was a postgraduate student.

The apartment’s wooden floors and clean white walls reminded me of the writer Bruce Chatwin, who wished to live in an aesthetically-pleasing bare flat, so kept a spare room stuffed to the gunnels with all the clutter he actually needed. I am travelling light – one suitcase and cabin bag – I have little clutter to distribute. I have set up a work space with my back to the amazing view of the John Hancock Tower. Sirens (ambulances ‘whoop’ here like exotic birds and fire engines have tuba-deep honks) sometimes raise the background hum of the street, but it is easy to work, and a nice alternative to libraries and archives (more on them in another post).

harvard fridgeWhen I arrived there was nothing in the fridge AT ALL, which intensified its enormous size (there must be an interesting history behind Americans and their fridges). I went shopping, a little fuzzy-headed from the jet lag, and artfully spaced my purchases on the middle shelf. The freezer compartment has an icemaker with a mind of its own. The first few nights I was woken by the sound of new ice being churned out. My initial reaction was to keep removing it, like Mickey Mouse with the buckets of water in the Sorcerer’s Apprentice…‌

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Motivations and justifications

Harvard

I am in Boston, well Cambridge to be precise, which is just across the Charles River from Boston, and home to Harvard University. I arrived here on 6 April as a Visiting Scholar. When I asked the Wellcome Trust if I could spend three months here (as part of my five year Senior Investigator Award) I half expected them to say no. But they didn’t, and in fact have been enthusiastic about building US collaborations for my research. More of that later.

Justifying the trip to my family and to my colleagues and students at Liverpool, was equally vital – and this blog is partly for them by way of a longer explanation of what happens on historians’ research trips. I usually keep a paper research diary when I am away from Liverpool – this is the first time I have attempted an electronic – and public – record of what I do on my travels.

‘What do you actually do?’ This question, with varying degrees of implicit scepticism about historical research, comes up regularly from non-historian colleagues, and especially from my undergraduate medical students. I often introduce myself as an ‘applied health policy historian’. What I mean by that is I research the historical context to contemporary health issues, and then use my findings to engage with policymakers – often in local and national government organisations. I have also ‘applied’ my research, especially on Liverpool’s public health history, to public engagement – collaborating with museums, hospitals and community groups to develop exhibitions and projects that capture and explain histories of health and health care.

My new project – the reason for spending three months ‘in Cambridge’ (as they prefer to say here – not ‘at Harvard’ – but I quickly found that confuses my colleagues, especially when fixing times for skype calls) – is called ‘The Governance of Health. Medical, economic and managerial expertise in Britain since 1948’. It investigates how the NHS has increasingly turned to health economists and commercial consulting firms such as McKinseys to try to make healthcare more efficient and cost effective. Many of the NHS policies have been drawn indirectly from US ideas. I want to explore how and why that has happened.

To answer these initial questions, I have to understand the development of the US health system, health economics, and ‘health decision science’. Harvard is an excellent location to do this: there are 70 libraries, and many of the key individuals who have shaped US healthcare are on campus (and, I have discovered, very willing to devote an hour to briefing me).

So, what am I ‘actually doing?’ here? A lot of reading: books, collections of personal papers held in archives (Harvard, Yale, New York, Washington DC, etc); interviews; having interesting conversations with academics and health activists on what they think of the US and UK healthcare systems.

As I have the time, I hope to write more posts – maybe some observations on US city living (enormous fridges…), the highs and lows of archive research (staying focused vs new lines of enquiry, the challenge of huge amounts of information), and what keeps travelling academic researchers motivated (often it’s food…)

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