The toughest challenges may require slow solutions

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From Stephen Colbert to Lean management bloggers, everybody seems to be talking about Harvard surgeon Atul Gawande’s latest New Yorker piece, “Slow Ideas.”

Looking back at two 19th-century medical innovations—surgical anesthesia and antiseptics to prevent infection—Dr. Gawande asks: Why was the first immediately adopted while the second took decades?

This question is pertinent for all of us who would love to see good changes spread fast. And it’s compelling as we at Group Health Research Institute tackle some of the toughest questions in health care:

  • How can we help people adopt healthy behaviors, avoiding chronic illness and premature death?
  • How can health systems provide care more effectively and efficiently?

Dr. Gawande contends that anesthesia was adopted fast because it provided an immediate solution to a visible problem. Giving ether before surgery meant no more writhing patients. By contrast, washing hands and tools with antiseptics addressed an invisible problem (microbes) without immediate gratification. The benefits appeared only in the future, obscuring cause and effect. Also, infection control was tedious and painstaking, and antiseptic solution burned doctors’ hands.

Despite the sacrifices required, health care workers eventually made great strides in infection control. Thanks to their slow, steady efforts, they transformed health care forever, preventing countless deaths from infection.

Likewise, GHRI’s work addresses some of today’s most intractable problems in health care—like smoking, heart disease, dementia, and depression. Solving these complex problems requires large investments of time and resources. And while our innovations in areas such as cancer screening, immunization, and smoking cessation have improved the lives of millions worldwide, we continue to see many puzzling twists and turns on our way toward progress:

  • Mammography: In a New England Journal of Medicine article last year, Drs. Archie Bleyer and Gilbert Welch showed that screening mammography has only marginally reduced the rate at which women present with advanced cancer. Meanwhile, current screening approaches may lead to overdiagnosis and overtreatment, harming patients and wasting resources.
  • Flu vaccine: As GHRI’s Vaccine Treatment and Evaluation Unit evaluates new vaccines for emerging viruses such as swine flu and bird flu, they’ve also discovered that some vaccines for more common flu are less effective than previously thought.
  • Smoking rates: Our research on tobacco cessation has revolutionized outreach, helping millions of smokers worldwide to quit. But meanwhile, a new Centers for Disease Control and Prevention study shows a slowing of progress in stopping teens from smoking.

Clearly, achieving progress in such areas can seem daunting. Just look at the recent landmark report in the Journal of the American Medical Association on trends in U.S. disease burden between 1990 and 2010. Despite “health expenditures that would have seemed unthinkable a generation ago, the health of the U.S. population has improved only gradually and fallen behind the pace of progress in many other wealthy nations,” wrote Dr. Harvey Fineberg, Institute of Medicine president, in an editorial accompanying the report.

Among 34 developed countries, the United States slipped from 18th to 27th in age-standardized death rates. America’s standing also fell in life expectancy, function, and quality of life.

The report says the leading risk factors for disability in the United States are dietary risks, smoking, high body mass index, high blood pressure, high fasting blood sugar, physical inactivity, and alcohol use. So Group Health researchers are focusing on the right things. But these are all tough problems with no magic-bullet solutions.

What is Dr. Gawande’s prescription? He urges against feeling discouraged by complexity. Instead, accept that many important solutions will not be instantly adopted just because someone has built an app or tweeted to the masses. Rather, solutions will require the spread of “slow ideas” through “high-touch” relationship building: mentorship, coaching, and one-on-one training. Here at GHRI, we will keep addressing health care’s toughest problems in similar ways: collaborating with providers, researchers, and patients at Group Health and beyond, on cycles of improvement within our learning health systems.

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