Monday, June 24, 2013

The Relationship Revolution

The Industrial Revolution is dated to the late 1700s, and the early 1800s.  It represented a massive change in manufacturing with society going from hand production to machine production.  This brought with it less poverty and increased living standards for a huge portion of the population.  It did not however go without its challenges as the Luddites of 18th century England fought the move from skilled artisans to machine production.  The Swing riots in England in the early 1800s fought threshing machines which were starting to transform agriculture just as the Luddites battled against machine production of textiles and other iron goods.  They fought because they saw what was being lost.  The personal relationship that a person had with the farmer, the shoemaker, and the furniture maker who were part of the community was no more.  That relationship and the connection to the source of the food and goods you use on a daily basis was real and brought appreciation and respect that took a back seat to the need for systematization and safety.  At that point in time, that trade off was appropriate and necessary as we brought millions of people out of hunger and poverty. 

While threshing machines started a transformation in agriculture, it was not until after the introduction of the tractor in World War I and the wide acceptance of the tractor (which did not occur until after WWII) and other large agricultural machinery that the family farmer began to fade from view and the industrial farm began its gradual domination over food production. That also brought lower cost food for the masses but even more distance from the local food produced with pride and even love. 

Society has progressed through technology and modern industrial systems.  We are fortunate to have easy access to food through our supermarkets and to clothes, furniture and other manufactured goods through our stores.  We don’t have to trek to the farm, and to the dressmaker, and to the cabinetmaker to buy individual goods.  This progress has freed us from the time and energy needed to access all those goods and services.  It has improved our ability to ensure a basic level of safety and quality in food and manufactured goods.  But it has cost us in terms of local relationships and connection to the people who bring us these goods. 
In many ways, health care has resisted this systematization perhaps due to the intensively personal nature of illness and suffering.  That resistance to systematization has hurt health care in terms of basic safety, minimal quality standards and easy access.  We are now in the midst of an upheaval in health care with an industrialization going on that can radically change health care, in many ways for the better, allowing more access to care and more efficiency in care delivery.  However we risk losing a personalization based on relationships that we have seen lost in manufacturing and in food production.  The lone doctor as an island fighting back disease and answerable to no one but the patient as he or she cares for the sick is somewhat romanticized however it is based on a “hand production” model that is fading from view and that is good!  But that lone doctor had a relationship with the patient that cannot and should not be lost.  The Luddites and the rioters in the Swing riots have, in today’s world been caricatured as those fighting progress however they had a point that a loss was taking place: a loss of human relationships and the pride and quality that goes with those relationships.  When we move to this industrialization of health care, can we maintain the human relationships as we reap the benefits of more consistency in quality and more access to care that the health care industrial revolution will bring? 

At Accolade we are trying to marry the industrialization of health care with a focus on building and maintaining relationships in order to get the best of both worlds.  On a recent trip to Seattle and San Francisco, I saw two other organizations, one in health care and one in food production and delivery that are attempting to do the same.  I believe that Accolade, Qliance and all represent a new revolution: the Relationship Revolution that is attempting to bring back the skill and pride of the lone physician, the artisan and the family farmer while retaining and even improving the access to goods and services and the quality assurance that is made available by industrial systems. 

Qliance is a multi-site primary care practice in the Seattle area which employs Internists, Family Physicians and Nurse Practitioners to serve their population.  They describe themselves as a “healthcare organization giving patients affordable access to highly skilled doctors, nurses, and healthcare teams”.  They have the appropriate management systems and computerized medical records to create efficiency and to ensure minimal levels of quality but at the same time they improve relationships between doctor and patient by fostering a sense of ownership by both the care giver and the care receiver.  By having each appointment be a minimum of half an hour, instead of the usual ten to fifteen minutes that is the norm in many practices, and by limiting the panel size of each primary care provider to no more than 800 patients, instead of the usual 2,500 patients in primary care practices, they are able to create a care model for each patient and for each primary care provider that maximizes the value of the primary care/patient link.  This is in contrast to the volume and production norm in most primary care practices that makes real relationships difficult to develop and maintain.  Patients can communicate with their health professional by phone, by email, or in person and receive the same time and attention.  They can reach a group health professional 24 hours a day, 7 days a week.  In the provision of primary care, they are part of this Relationship Revolution. 

Good Eggs is a company started by a group of young idealists, including my son Rob that has grown into a team of more than fifty people in four cities around the country.  Good Eggs mission is to “grow and sustain local food systems worldwide”.  Using industrial and advanced technological techniques, they are bringing locally sourced groceries from local farmers and food makers direct to people’s homes; the groceries are picked and prepped to order.  They are recreating the relationship between the farmer, the bread maker, the local food preparer and other food artisans that occurred when one went directly to a farm to talk to the farmer while picking up fresh food.  Relationships are formed with the producers of this food and the pride and quality that the people who produced your food have is fostered while at the same time the access and quality that is brought about by industrialization and systematization is maintained and improved.

At Accolade, we have created the new profession of Health Assistant.  With health care being so fragmented and requiring the interplay of insurance, regulations, primary care, specialty care, diagnostics, therapies, medical equipment, and other personal and social factors, a professional is needed.  Physicians and medical practices do not have the details and the knowledge of their patient’s disparate financial, insurance and work related factors while a Health Assistance has access to all of these puzzle pieces and the skills and training to coordinate all these factors for people in need.  We have created the profession and the systems to support that person and their Health Assistant as they go through the health system.  We offer the personal relationship that is sorely needed when one is in need of health care help while we foster the consistency, availability and affordability that is the promise of better systematization.  We are on the forefront of the Relationship Revolution. 

Health care will benefit from the industrialization that is now taking place some 200 years after the Industrial Revolution started.  However, in health care, it is even more important to maintain the personal relationships that are inherent in the caring fields of medicine, nursing and other health professions.  This requires a Relationship Revolution as much as it requires an Industrial Revolution.  It is far too easy, in our zeal to create reform, access, and a minimal level of quality to ignore the relationships that underscore each and every health care interaction.  Health professionals have a mission to treat everyone as if they were family, as we also take full advantage of the most up to date information and communication technologies.  This will fulfill the promise of improving care for all of us.  

Saturday, June 8, 2013

Culture and Medical Care

It is now 25 years since Lynn Payer wrote “Medicine and Culture: Varieties of Treatment in the United States, England, West Germany and France”.  Published in 1988, Ms. Payer’s book imparts a message that should be repeated frequently.  The message is that medicine is cultural and not only scientific.  Despite the fact that different countries have the same results as measured by mortality rates, the care differs significantly in the types and quantities of drugs used, in the kinds and numbers of operations performed and even in the definitions of what is “within normal limits” and what requires treatment.  She made the observation that these differences in the approach to illness can be explained by differences in culture and values ingrained over hundreds of years. 

Ms. Payer wrote this book while she lived as an American in Paris, working as the health and science reporter for an American newspaper.  She had lived her whole life in the US, having been born in Kansas and had then spent 8 years in Paris working and writing.  Ms. Payer died too soon in 2001 at the age of 56 from breast cancer. 

I find myself picking up and re-reading her book from time to time to get inspired by the simplicity of her message and the profound implications of what she had observed.  So much of medical decision making is cultural and values driven.  Even though medicine has a scientific backbone, the way the science is used by doctors and patients alike, is based on values and trust.  Culture is important because therapeutics must be based on a trust bond between health professional and patient.  That trust bond is built by understanding and communicating values and cultural norms in a way that reflects respect for and autonomy of the person in need.  If you don’t understand and accept the differences of people in the four western democracies that Ms. Payer describes in her book, you cannot understand and accept the differences in people from far more diverse cultures.  In order to be effective in truly touching that person in need and foster healing, a health professional must meet that person on their terms.  That holds true for all cultures around the world and also holds true for differences in cultural norms in different regions of the United States.  It even holds true for different subcultures related to schooling, profession, and socioeconomic status. 

A recent case in point at my company Accolade brought all this to mind.  A young woman from an English speaking country was transferred to the United States by her company.  This brilliant scientist found herself in the exciting yet daunting position of gaining a promotion but also having to move to a new culture.  Language was not an issue however changing cultures can still be quite difficult.  Her Health Assistant at Accolade had been helping her intermittently with understanding her health benefits and her health plan as this was totally foreign to her since her move to the US.  This stress was taken to a new level when she became ill and was admitted to the hospital.  In the hospital, the cultural challenges intensified.  She was told that she had to have a procedure and that without the procedure, treatment could not be initiated.  She then asked what the complication rate of the procedure was and was told that she would do fine, and that the complication rate was only 1 in 100.  As she was in a teaching hospital, the message was given by a doctor in training, a resident, and the doctors appeared to her to change on a daily basis.  She felt alone, frightened, and even in danger.  For a scientist used to working with quality parameters of 1 in 250,000, 1 in 100 seemed barbaric.  She interpreted this as meaning that since a doctor in training, who was not very well trained, was going to do this procedure they expected it to be much riskier than it had to be.  They also told her that she was too sick to be discharged from the hospital and that she either had to have the procedure or just get sicker.  She had no options.
She felt like a prisoner.  She felt as though there was no one on her side.  At that point her Accolade Health Assistant®, Kate, was the only person she could turn to.  The patient was speaking to Kate, who she was starting to trust, on a daily basis.  Kate, understood that she did not have all the expertise in that young woman’s cultural background that she needed so she turned to another Accolade employee, Mary, who is not usually on the front lines with people in need, but who came from the same region of the same country as this young woman.  Mary immediately coached Kate on communication norms that would help to build trust. Subsequent phone calls reflected that cultural intelligence in communication.  After a few calls, that trust bond was strengthened in order to help this young woman through her illness. Mary also began to talk with her on the phone creating more trust for the entire team at Accolade.
The end result was a patient who felt supported and empowered and who was able to subsequently be transferred to another hospital in order to have a fresh start in building trust with a new medical staff in order to move therapy forward.  It did turn out in the new hospital that the previous well known teaching hospital had been giving her medication in doses that was toxic to her liver.  That toxic effect was reversed and she started to improve. 

I think about all this and wonder if evidence based guidelines which are purely based on science, and not on culture or values, leave out a critical point.  I wonder if the push for productivity that forces doctors and nurses to spend less time finding out the values and cultures of the people in need sitting in front of them will ultimately lead to worse care.  I wonder if we can maintain and even improve our ability to effectively treat people in a way that values them as autonomous independent people when we seem to be pushing in the opposite direction, even with the best of intentions to try to build a more sustainable system from a cost perspective.  Ultimately, medicine is personal with one person touching another in a way that is intimate, honorable, and respectful of all that the person in need is as a fellow human being.  We should accept nothing less as health professionals or as patients.