Trusted Leader - May 2008
By Larry BeSaw
Josie R. Williams, MD, has a good memory, but there's one that escapes her.
"I do not remember when I was not going to be a doctor. I can remember sitting in church and in grade school and writing 'J.R. Williams, MD.'"
Becoming a physician was young Josie's dream, but at the time, she wondered how she would achieve it. Money was the problem. The daughter of a World War II machine gunner-turned cowboy who took his family wherever he could find work, Dr. Williams grew up all over the Southwest, from Texas to Oklahoma to New Mexico. She attended nine schools by the time she was in the ninth grade, finally finishing high school in Oklahoma.
During that time, there was work. Backbreaking work.
"We built fences, we herded sheep. I ran a Grade A dairy for my dad from the time I was 13 on. Literally, I was his primary hand."
Because there was no money for college, she opted for nursing school, paying her tuition by selling 40 head of cattle on the Saturday before she enrolled on Monday. Still, times were hard. The $5 a week her mother sent her helped, but she had to work at several different jobs while studying to become a nurse.
She made it through Sparks Memorial Hospital School of Nursing in Fort Smith, Ark., graduating in 1962, but the dream of becoming a doctor lived on. After taking a year off to work to pay bills "and play a little bit," Dr. Williams joined the U.S. Air Force so she could qualify for GI Bill benefits to pay for college.
Her Air Force nursing experience included being surgical ward nurse at USAF Hospital, Ellsworth AFB in South Dakota, then 18 months at Clark Air Base in the Philippines, where she cared for Vietnam War casualties in the surgical intensive care unit. She went on to become chief nurse at Bergstrom AFB in Austin, earning an Air Force commendation medal for her work there.
After the Air Force, Dr. Williams enrolled at Texas A&M, thus becoming, as Howard Gravett, MD, pre-med advisor at the time, told her, "the first woman to go to A&M, graduate from A&M, and go to med school."
In 1975, she earned her medical degree from The University of Texas Health Science Center at San Antonio Medical School. Finally, after all those years of sacrifice and struggle, she was able to write, "J.R. Williams, MD."
During a career as a gastroenterologist and internal medicine specialist in Paris in Northeast Texas, Dr. Williams developed an interest in quality of care, eventually becoming a national expert on measuring quality.
She was medical director of the Texas Health Quality Alliance from 1998 to 2001 and is a member of the National Patient Safety Foundation Board of Governors. She also is on the Board of Trustees of the American Medical Association's Physician Consortium for Performance Improvement.
Currently, Dr. Williams is assistant professor in the Department of Internal Medicine at Texas A&M University System Health Science Center College of Medicine. She is director of the Rural and Community Health Institute and the Institute for Healthcare Evaluation at Texas A&M, where she specializes in quality and patient safety initiatives. Before being appointed director of the Rural and Community Health Institute, she directed the Quality and Patient Safety program at the Texas A&M Health Science Center.
Dr. Williams has a long history of involvement with the Texas Medical Association. She served on the Board of Trustees from 2001 until her selection as president-elect and has been a Texas delegate to the American Medical Association since 1994. She's served on various TMA councils and committees, including the Council on Legislation (2000-01), the Council on Socioeconomics (1994-2000), the Texas Health Care Information Center Technical Advisory Committee (1997), the Special Technical Advisory Committee to the Governor's Task Force on Health Care Reform (1993-94), and the Quality Committee (1992-96).
On May 3, Dr. Williams added another accomplishment to her resume when she became TMA's 143rd president during TexMed 2008 in San Antonio.
Texas Medicine interviewed Dr. Williams about her career and what she hopes to accomplish as TMA president.
Texas Medicine: Did your experience as a nurse make you a better physician?
Dr. Williams: Absolutely. Nurses are taught to communicate with patients first. Knowing how many times the doctor had left the room, and I had spent the following 30 minutes trying to tell the family what the doctor had said, made me a better physician. It gave me a much better sense of what the patient was worried about, what the patient really wanted, what the patient understood and didn't understand than I ever would have if I hadn't been a nurse first.
It also taught me what a sick patient was. I knew what a sick patient was long before I went to med school, and I knew when a patient was turning south long before I went to med school. That allowed me to focus on medicine, not on trying to decide if this patient was sick or not. I could go into a room and do a nursing assessment and know whether the patient was sick or not and have some sense of if there had been a change since the last time I saw him or her. I credit my being a nurse with being an honor student in medical school.
Texas Medicine: How did you get interested in quality issues?
Dr. Williams : In 1982, I was dealing with a patient who had hepatitis C and was very ill. I had just talked to Dr. Lee in Dallas, whom I knew personally, and who was a world expert on this disease. He said I was on the right track.
Then, the next day, I fought with an insurance agent who told me I should not be giving IV cyclosporine in Paris, Texas. It made me livid. I was board certified in internal medicine, residency trained in GI, and this guy was questioning whether I should be doing it or not. I got mad, just like most doctors do, and I reacted just like most doctors do.
Then, I thought, this is stupid. If we're so smart, why can't I explain to this man that this is one of my sicker patients and, yes, she needs this drug, and, yes, she's perfectly fine here. If that's the case, why can't I explain that? Where are my numbers to prove it? How do I differentiate my quality from the guy's next door?
And as I asked myself those hard questions, there were no answers. I had no idea what my practice was compared with anyone else's. That disturbed me. I talked to Dr. Tom Riordan at AMA, who was then a Board of Trustees member and upcoming president, and he said to me, "If you really want to make a contribution to medicine, you really will find out what quality is, how to develop it, and how to measure it."
It started an incredible change in my entire career. It changed the way I look at things, and it made me face some hard questions and some hard answers. We're good scientists in saying what to do; we're lousy about saying how to do it. We do not know whether our practices are good or bad. We do not know the best way to deliver health care. That's what's driven me throughout my entire career. If we're good scientists, as we should be, and if we truly are about caring for patients, then we don't just want to know how to do it or what to do; we want to know what's the safest, quality way that is patient-centered and the most effective way to do that.
Texas Medicine : Have you run into resistance from other physicians?
Dr. Williams: Absolutely. They don't understand it. They don't understand that we talk about disease as being measured in 1 per 100,000 or 1 per 10,000, yet we very rarely realize that in our own experience we see 30,000 to 50,000 patients total. My lifetime experience alone says very little.
Those small numbers make us feel like an error was just one of those things. You didn't say anything and it happened to me, and I didn't say anything and it happened to him, but he didn't say anything, so now we have three incidents where we may have harmed one patient; but over medicine as a whole that may be 100,000, it may be 70,000 or 80,000, it may be nine patients we could have saved had we all known we'd had that issue.
Texas Medicine : Did the Institute of Medicine's To Err is Human report that said 98,000 patients a year die in hospitals from medical errors have a lot to do with changing physicians' perceptions of quality?
Dr. Williams: I think it brought people's attention to the problem. People were all concerned about it and thought it was flawed and that there were a lot of problems with it. Those of us who work in quality think they were wrong. The report's numbers were not correct. It's worse than that. It is wrong by some-fold, but until we really evaluate it, we don't know how wrong.
The other thing that bothers me is that no one quotes the other 25+ reports on quality that came out of the Institute of Medicine since 1999 that don't bash doctors. To Err is Human was not about how bad we are. It said we need to look at how we deliver care. If we do this right, we could do a better job.
Texas Medicine : Are you finding that physicians are becoming less resistant to your quality efforts?
Dr. Williams: I think it depends on the way they are approached. Many people are beginning to get the message and see the data and read the literature that we really don't do as well as we think we do. It's based on slips and lapses. Slips and lapses are straight out of the literature about safety, not just patient safety, but safety overall. Did you ever walk out in the morning without your car keys?
Texas Medicine: Sure.
Dr. Williams: That's a slip. Is that human?
Texas Medicine: Sure it is.
Dr. Williams: So if you're in the middle of a heated operation and you're doing five gazillion things and somebody distracts you, do you think you might have a slip?
Texas Medicine: Absolutely.
Dr. Williams: Duh! That's what we're talking about. How can we build our systems to the point where they are fail-safe? Or at least as fail-safe as possible. At least build a system that minimizes harm. That's what they're asking us to do in medicine. Those are the things we have to do if we're really going to continue to be the leaders in health care.
Texas Medicine : Are you worried that if physicians don't do it, someone else will do it for them?
Dr. Williams: They are doing it for us. They're doing it now and doing a lousy job. The insurance companies … big business. Big business is driving this now because they can't afford what we're doing.
Texas Medicine : What do you hope to accomplish in your presidential year?
Dr. Williams: Number one, a new vision. Number two, a glimmer of hope that we can drive this ship better than they can drive this ship.
Texas Medicine : What do you mean by a new vision?
Dr. Williams: I believe health care is in shambles, just like other doctors believe it is. I believe the payment system is in shambles, just like they believe it is. I also believe we can learn a better way to deliver health care. I'm not even sure what that is, right now, but I believe that as far as the vision and wisdom of physicians, TMA might as well lead that bandwagon. I believe that collectively as physicians, we can put our heads together and we can find the solutions better than government.
Texas Medicine : How do you convince your colleagues of that?
Dr. Williams: I don't know that I will. When I started talking about performance measures 20 years ago, they thought I was crazy. Today, they're not talking about me being crazy anymore; they're saying, "What are you talking about? How does it work?"
My job is to open the door and for them to understand that we're the only people who can salvage medicine today. We have to believe that we can learn not only a defensive strategy, but also an offensive strategy. We can realize that we have put up with a lot for so many years.
A perfect example comes to mind. For 30 years, we have argued about how unsafe the pumps they put on IVs are. They're just now fixing it because we just accepted it for all those years. We didn't say "not no, but hell no" to a pump that doesn't work. We didn't send it back to the distributor. We didn't send it back to the manufacturer. We didn't call their bluff, so we had equipment that didn't work.
We don't understand the science, and we don't look at the science of performance or of systems that might inform us. We learned to do it one way and we've always done it that way. In 1950, that worked. When I graduated from medical school in 1975, there were a little more than 2000 randomized control trials. Last year, there were 20,000. Things are so much more complex than they ever were, you cannot humanly keep up with that without building a system that works, not just for you, but your entire unit, your entire facility. We're going to be in a living hell until we do it.
The only hope is that we keep a strong defense, strong liability reform, strong push to get paid for what you do. The other thing we must do is lead on what is quality of care. We can learn a better way to deliver health care. We can learn the dangers of the health care that we deliver today.
We reserve the right to police ourselves. When we lose that right, when we give that right away, we are no longer a profession but a trade, and I'm not willing for us to go there.
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