Wednesday, November 27, 2013

Thanksgiving, Kate Penny and the Medical Advisory Board

In my last blog post, I spoke about Accolade’s new Medical Advisory Board and the caring smart people who serve on that Board.  I also described two cases, including one of helping a patient who had end stage cancer, that Accolade nurses presented for discussion at the meeting.  Kate Penny is one of the talented nurse who presented and this is her reflection on that meeting:

"I wanted to thank you all for the privilege of presenting at our very first Medical Advisory Board. It was both a great learning opportunity and a tremendous experience.  I found the Advisory Board to be both kind, and thoughtful with their questions. 

In retrospect, I believe I did a less than a stellar job in representing M_____ and differentiating Accolade’s mission and values (Alan editorial comment – a stellar job was done).  Working with M_____, we added value. We dealt with claims, appeals, pain control, prevented unnecessary procedures and educated and supported the family. M______ gave me much more than I gave her. She let me share in her grief so that I was able to share in her love. We were together in wondrous times and witnessed the miracle of life and death together. We shared joy, sorrow, courage and tenderness. It was real. Kindness, tears and laughter are the currency of the heart, and meant to be exchanged.

M______ lived in constant terror of dying. She viewed her life as if it were a past event, and for many months defined herself solely by her terminal disease. M_____ had forgotten that she was a soul with a body, not a body with a soul. “Operation Love” helped her remember that for a short time. M_____ died peacefully and with grace. How do you communicate this in terms of metrics and statically project these measurements? Active love and listening goes beyond engagement and feelings of connected moments. It is looking for what is needed and providing it. It’s realizing that what needs to be done, is for you to do.

I have the privilege to witness this daily in the Health Assistance Center on so many levels with my co-workers, often unrecognized by others. It humbles me. My team mates and leadership are acutely aware of my strengths and weaknesses and they continue to educate, support and encourage with love. There are days when you feel like there is not one microgram left to give. I look around me and hear the passion to serve or just get it right and am inspired by my colleague’s devotion.

One of the Medical Advisory Board participants asked the “what’s the secret sauce?” question. People, stop over thinking it…it’s the people! We’ve learned and employed our beautiful model. We work hard to engage and build relationships. Once that has been achieved, the real work begins. We take the journey with the client and often share some of the most intimate moments of their lives. Health Assistants and Clinical Health Assistants have been empowered to do this and share the dream. The dream to change health care in the most unique way I have ever witnessed in a corporate setting. Just do the right thing!

In past years my family had a tradition at Thanksgiving of writing short letters of gratitude. I would like to continue that tradition with my Accolade family. I am most blessed because of each of you.
I am grateful for the sense of community I experience daily.
I am grateful to simply be accepted here as me. You have allowed me to combine both the art and science of nursing, a dream come true.
In short, each one of you at Accolade has given me purpose and enriched my life. For that, I will always be grateful."

Monday, November 25, 2013

Smart, Caring People Changing the World

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has. – Margaret Mead

These days, the news is filled with stories about the political strife surrounding the Affordable Care Act rollout. As I listen and read, I worry that individuals in need--who are dealing with their own and their family members’ illnesses--are being given short shrift in a debate driven by poll numbers, congressional races, and ideology. Yet I still have hope about the future of healthcare.  That’s because I spent two days last week with Accolade’s newly formed Medical Advisory Board. These renowned healthcare professionals came together to discuss ways to improve the care we provide and, despite their national prominence and expertise in health policy, were totally focused on how these policies and programs affect individuals and their families.

I admit to being a bit awestruck by the people who sat together to discuss ways that we at Accolade could better help people in need.  

  • Dr. Joseph Betancourt, the director of the Disparities Solutions Center, director of Multicultural Education for Massachusetts General Hospital, associate professor of medicine at Harvard Medical School, and an expert in quality of care, disparities, and cross-cultural care and communication talked about ways to better help people by understanding their unique cultures
  • Dr. Samuel (Buddy) Hammerman,  senior vice president and chief medical officer for Select Medical—where he oversees the company's division of 110 long-term acute care hospitals—uses his expertise in pulmonary medicine and critical care to ensure that every single patient in these facilities receives excellent care.
  • Dr. Larry Kaiser, the CEO of the Temple University Health System, senior executive vice president for the Health Sciences, and dean of Temple University School of Medicine, is a world-renowned chest surgeon and the co-author of more than 13 books and 250 papers, but he is as deeply concerned about the high-needs population his health system serves as he is about the academic responsibilities of research and training new dedicated health professionals.
  • Dr. Bruce Korf, chair of the Department of Genetics, and director of the Heflin Center for Genomic Sciences at the University of Alabama at Birmingham, is focused on children and families who deal every day with the challenges of complex genetic diseases, including neurofibromatosis; he spoke of the need to better address families with these challenges.
  • Dr. Andrew Lasher, chief medical officer of Aspire Healthcare, is one of the nation’s bright lights in palliative care and a physician totally dedicated to using compassion when caring for the dying.
  • Dr. Adam Perlman, associate vice president for Health and Wellness for the Duke University Health System, and executive director of Duke Integrative Medicine, is working to meld alternative medicine and the best of academic medicine into results for the most difficult patient problems.
  • Dr. Saul Weiner, professor of medicine, pediatrics and medical education and vice provost of planning and programs at the University of Illinois at Chicago as well as deputy director of the Veterans Affairs (VA) Center of Innovation for Complex Chronic Healthcare is conducting cutting-edge research on how the context of life issues impacts the delivery of care; he has begun to change the conversations about what “best care” really is. 

We were also joined by Dr. Tanya Benenson, the corporate medical director for Comcast NBCUniversal; she worries about the health of the Comcast call center worker while at the same time she worries about the talented individuals NBC has working around the world. 

Throughout the time together, these smart caring people talked about individual patient cases and how to better help them. 

We discussed the 50-year-old man, originally from Cuba, whose wife had recently died of cancer; he had a history of drug abuse, was on anticoagulation for heart disease, and had diabetes.  This man was having trouble communicating with his doctors and was therefore not taking his medications as he should, but was too proud to admit his difficulties.  The Accolade nurse who helped him got to know him, talking with him in both English and Spanish, gaining his trust and changing his life as his medical illnesses and his behavioral illnesses came under closer control.  Our Medical Advisory Board sat listening and shared their insights on how to improve his care even more.

We discussed the woman dying of ovarian cancer, and the need to incorporate her large family in the discussion as she moved into hospice care.  The Accolade nurse talked about the trust she formed with this woman as she helped the person accept her diagnosis and prognosis and how her last days were made better by being open with her family.  She discussed the work done to help this woman move to hospice care in order to have more quality time with her son.  The national leaders around the table were as energetic and thoughtful about those individuals as they were about how to improve a nation’s healthcare system.

Over and over, I see the best and the brightest people in healthcare sharing the perspective of the individual and the family in need.  This week I was again reminded that healthcare is not about politics, but about people’s lives, and the real leaders in health understand this and incorporate that compassion and focus on families into everything they do.   

Monday, November 4, 2013

Health Professionalism: More than Following Algorithms

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” Sir William Osler (1849 – 1919)

I use--and perhaps overuse--this quote by William Osler, who is considered to be one of the fathers of modern medicine.  As a physician, I have always believed that understanding the patient, and not only the illness, is the key to effective therapeutics. However, today there are many who believe that the future of effective therapeutics lies in use of standardized approaches and in computerized systems --rather than in the ability to understand the person who has the disease. 

There are those who even believe that we are approaching the point at which doctors, nurses and other health professionals may be unnecessary.   The belief is that as evidence-based algorithms get more sophisticated--and computers and apps provide the platforms for their use--the need for a professional disappears.  Yet I worry about the loss of professionals and the loss of professionalism.  I am not the only one to worry.  A recent article in The Journal of the American Medical Association (JAMA) and a recent blog from the American Journal of Nursing suggest that I am not alone in my concern that blind faith in technology and algorithms may not provide a panacea. 

In the JAMA article “The Optimal Practice of Evidence- Based Medicine,” three physicians from the Mayo Clinic state that “research evidence is necessary but insufficient for making patient care decisions.” They go on to say that “careful attention to the bio-psychosocial context of patients and to their informed preferences when crafting treatments requires expertise and practical wisdom.”  Their article focuses on incorporating patient preferences into guidelines, however they also argue for a certain expertise and judgment that is part of professionalism.  They make the point that “guideline panels should rarely formulate strong recommendations.  Panels should become much more comfortable with ambiguity, both in the tradeoffs involved and in the recommendations given, and explicitly report how patient preferences and context were considered in formulating the panels’ recommendations.”  Presumably, if the guidelines are partially based in ambiguity and patient preferences--which vary from patient to patient and are part of the puzzle--an experienced professional who can customize those guidelines is a critical element of good care. 

In a blog post from the American Journal of Nursing, Karen Roush, a nurse practitioner, discusses her experience working in a retail clinic. She ultimately left that position because, she says, “the computer was in control. From the moment the patient checked in at the kiosk outside my door, every action was determined by the computer…The organization I worked for prided itself on following evidence-based practice, but someone forgot to tell them that the patient’s history, presentation, and personal experience, as well as a clinician’s expert knowledge, are also part of the evidence.”  She spoke of her slavery to the computer leading to bad medicine:  “It interferes with two really important skills – critical thinking and intuition based on experience.” 

Ms. Roush, in speaking about critical thinking and intuition based on experience, is talking about elements of healthcare professionalism.  Professionalism implies a certain moral commitment and an ethical approach that is individualized and transcends any particular job a professional may hold.  Lynne Kirk, in a 2007 article in the Proceedings of the Baylor University Medical School, gives a variety of definitions of medical professionalism and notes that all the definitions share a focus on patient welfare, altruism and trust:  “Market forces, societal pressures and administrative exigencies must not compromise this principle.”  Definitions of medical professionalism also share a commitment to patient autonomy, which implies being honest with patients and empowering them to make their own appropriate medical decisions.  

Tom Lee from Harvard and Partners Health System in Boston makes this point, as well, in a Health Affairs  blog post-- “Patient Experience Will Drive a Renewal of Professionalism”--in which he advocates for more robust measurement of true patient preferences and patient experience.  He writes: “My strong belief is the emerging focus on measurement of the patient experience takes health care in the right direction, one that will restore and give new pride to physicians and other clinicians.”  Notice he uses the word “restore” in acknowledging that in our present medical world, professional pride may be lost.  He goes on to say that we have to understand patients’ needs.  “Measuring patient needs is the right focus for physicians and other clinicians. It is the essence of professionalism.  What is not the core of professionalism is performing high volumes of services that are reimbursed under the fee for service system.  Nor is reducing spending on populations of patients under capitated contracts.  Neither of these business objectives are inherently wrong, but these financial strategies are of limited relevance to any thoughtful sense of professionalism for clinicians.”
Accolade Health Assistants®, when helping clients with needs that are clinical and social and psychological and financial, have to maintain professionalism at all times.  We are professionals helping people and to be effective, we will always use and communicate best practice, evidence-based protocols.  At the same time, we will always customize those protocols so that the autonomy and unique aspects of every person is respected.  We will, as an organization, work to better develop our own algorithms and evidence-based protocols that address our clients’ social, emotional and financial needs in relation to their clinical needs.  At the end of the day, we will also use our own critical thinking--and even intuition based on experience--as Karen Roush says, to help meet the needs of those people we help every day.