A Declaration of
debt over the past 30 years has grown from
$900 billion to $15.5 trillion. The solution is
clearly not more health-care spending.
By Norman J. Beauchamp Jr.
2013–2014 ARRS President
On July 4, 1776, our nation put for- ward a declaration, a Declaration of Independence. This call to independence, creating separation from the rule
of Great Britain, also established a cultural
norm of individualism. For 239 years, the
citizens of our great nation have embraced,
been energized by, and been rewarded for
The drive to be the best “one,” whether
as a student, clinician, scientist, medical
specialty, or medical institution, has fostered a competitiveness that has fueled
many great scientific and medical advances. Consider that over the past 30 years,
life expectancy has increased 6 years and
morbidity has decreased 30 percent. The
prior 40 years also witnessed the development and refinement of CT and MRI,
which were rated by a panel of Nobel Prize
winners to be among the 10 most important
advances in medicine in the past century.
Unfortunately, the focus on individual
accomplishment is not without its down-side. A substantial number of individuals in
our nation are “independent” from adequate access to health care. There is fragmentation, waste, and lack of efficiency.
There is also an absence of coordination of
care and lack of standardization, which
contribute to the 100,000 needless patient
deaths each year [ 1].
Current health-care spending in the
United States is not sustainable. The total
cost for health care per family in 2012 was
$20,278, whereas the median family income was $50,054 . Forty-t wo percent of
federal spending is devoted to social welfare and health-care costs, and the federal
The truths that were declared self-evident for all—that is, life, liberty, and the
pursuit of happiness—remain elusive for
far too great a segment of our population.
We can do better. We must do better. But
what does better look like? The Institute
for Healthcare Improvement defines it as
the Triple Aim: the Best Care for the Whole
Population at the Lowest Cost. Don
Berwick, former president of the institute
and former administrator of the Centers
for Medicare & Medicaid Services, articulates it as:
No Unwanted Waiting
No One Left Out.
In other words, these are the health-care
“inalienable rights” that we must ensure all
our patients are given.
The Triple Aim requires that we work
together, not independently. However, the
challenge, as posited, is that the American
way is just the opposite—independence,
not teamwork. For example, researchers at
Stanford asked a group of students to eval-
uate how hard they would try if their grade
were based on group performance versus
how hard they would work if their grade
were based on individual performance.
The investigators found that those who
were called to work and be assessed as a
team worked significantly less hard [ 3].
Defined as the tendency to reduce one’s ef-
fort when working collectively, “social loaf-
ing” is particularly daunting because it has
been shown to worsen as the size of the
group or the complexity of the challenges
increases [ 4, 5]. Given the size and scope
of health care, it is perhaps predictable that
the health-care system effectiveness rat-
ing is on par with bungee jumping or mo-
torcycle racing [ 6]. Succinctly, American
culture stresses independence, and inde-
pendence fuels behavior. But the call for
partnership is “demotivating.”
It is for this reason that we must go be-
yond merely inviting partnership. We must
declare it to be the imperative, the vital be-
havior that if prioritized will enable our
success. We must make health-care’s dec-
laration a Declaration of Interdependence.
We must keep this declaration front and
center or “culture” will take its course. We
must also identify a limited number of
readily implementable partnership “criti-
cal behaviors” [ 7].
“We need to work interdependently with other health-care
professionals, hospitals, and clinics to ensure efficient health
care at the lowest possible cost.”
The patient/family and radiologist partnership is the most essential. We must
translate the patient/family needs and
wants into tactics and initiatives. Very simple efforts tremendously impact patient
satisfaction. For example, at the University
of Washington (UW), we implemented a
process in which we provide patients a no-tecard that gives them a record of who provided them care during their visit to our
department and whom to contact with
questions, from clerk to nurse to technologist to doctor. We also implemented the
Studer AIDET model, a framework for
care providers to communicate better with
patients and their families. “A” stands for
acknowledging or greeting the patient and
family, “I” is the care provider introducing
himself/herself, “D” is informing the patient and family about the duration of the
wait and the examination, “E” is explaining what to expect during the diagnostic
examination or therapy, and “T” is thanking them for seeking our care.
We must improve our partnership with
those who are specifically trained in systems optimization. Many of our universities have departments of industrial
engineering. For example, at UW, senior
students in industrial engineering complete a systems optimization capstone project in our department of radiology. It is an
interdependence that requires no exchange of funds, only access to the great
breadth of improvement opportunities the
complex health-care environment presents.
We must then seek to more effectively
make these best practices the standard