I ended an article in last month's issue of Southern California Physician on an ominous note: seeking a requiem for my chosen specialty of Family Practice. Over the past few months, however, I have started to sense a new reality. It starts from analyzing successes in reducing the risk associated with heart attacks and improvements in aviation safety.

In the first example, the American College of Cardiology established a goal of reducing the time from onset of Acute Coronary Syndrome (ACS) with ST Elevated Myocardial Infarction (STEMI) to the patient's arrival at the invasive catheter laboratory. Ninety minutes from onset to invasion became the goal. Our cardiology department together with the emergency department and all other key personnel took on the challenge. While the goal was to reduce the time from onset to arrival at the invasive catheter laboratory was 90 minutes, our best time to date clocked in at a mere 22 minutes.

To achieve our goal, we had to disrupt the usual flow of patient care. When the patient calls 911 and the paramedics respond, an electrocardiogram is performed on-site and transmitted to the base station ED. The electrocardiogram is interpreted immediately; if it is a STEMI all players are alerted. While the patient travels to the ED, the cardiology team (cardiologist, catheter lab staff, laboratory staff) start assembling. Upon arrival the patient often bypasses the ED and goes directly to the catheter lab. This protocol saves the STEMI patient's cardiac muscle and perhaps their life.

Rather than involving many players and processes to get to the catheter lab, the protocol directs the flow. This relates to one form of acute event but the success in managing this event stimulated similar protocols for stroke and abdominal pain. Unfortunately in the inpatient setting ignorance of the protocols resulted in a delay of care. An ACS on a medical ward often followed traditional patterns: nurse calls attending, attending orders an EKG, the EKG is performed and the doctor is notified, a cardiology consult is requested, and then a decision is made to intervene. Would the inpatient receive better, faster care if the nurse called 911?

In the world of commercial aviation, the issue of safety became the flying public's prime concern after the devastating crash of two 747 aircraft at Tenerife Airport in the Canary Islands. Apparently a pilot ignored the advice of his crew and chose to take off in total fog conditions; he assumed the runway was clear. His independent decision caused his 747 to ram directly into another 747 crossing the same runway. An analysis of this major accident established a series of protocols that effectively reduced the all-powerful decision making of the pilot. Any decision of the pilot can be challenged by any crewmember and the pilot must respond immediately giving the rational for the decision. Aviation safety achieved great success by critical self-analysis and protocol development.

Because of historical successes such as these, I propose that a similar analysis of medical care delivery for chronic disease occur. Most specialty care societies develop guidelines for care of major chronic disease states such as diabetes, asthma, and hypertension. The application of these protocols can be delivered by any number of providers. Mass screening of patients by simple lab testing annually would trigger diagnoses. Once diagnosed the patient plugs into a diagnosis protocol managed by a provider. Alas, who should be the "provider"?

The looming crisis in Medicare reimbursement could answer this question as well as create the environment for a critical analysis of medical care delivery. In aviation, if you don't like the commercial environment you can always purchase your jet or take a different form of transportation. You are in control.

Similarly, Medicare (insurers would follow) could easily expand to include "any willing provider" and establish tiers of payment. Incorporating any number of provider types such as physician assistants, nurse practitioners, holistic health providers, acupuncturists, and natural health providers-all of whom would need to comply with the protocols-would create a competitive marketplace for Medicare patients. Allowing providers flexibility in billing and allowing patients to choose their provider could solve Medicare's financial crisis. Patients could pay for services rendered and request a partial rebate based upon provider type from Medicare. Physicians of all specialties would compete for Medicare business. Medicare would monitor quality of care according to established protocols.

As hospitals become more closed systems with hospitalists of all specialties, competition for referrals may increase to all "willing providers". Hospital-based protocols similarly will improve safety and stabilize similar medical quality. Competition will focus on patient satisfaction, food quality, and environment. Will hospitals resort to different levels of food service?

Yes, medical care delivery may follow commercial aviation's model for delivery of service. Will the medical industry adjust to current realities? Yes, CMS plans to continue the Medicare cuts to physicians in July. How will we respond? Please have a safe flight!

Lytton W. Smith, MD, editor for the OCMA, is a physician practicing family medicine with the St. Jude Heritage Medical Group in Yorba Linda. Dr. Smith welcomes feedback on his articles and can be reached at editor@socalphys.com.