Friday, July 25, 2014

Care and Medical Intervention: Are They the Same?

People occasionally need care, and people occasionally need medical intervention.  We often confuse the two.  No one is 100% healthy and we all carry risk of disease, and often live with minor or major symptoms that modern medicine is not equipped to impact.  Many of us live with the label of having a chronic disease.  Despite this, our American culture fosters the myth that all illness and even death is optional, and can be overcome just by our own actions or the right medical interventions. The myth would be funny if the results were not so tragic – both for individuals and for society.  All of us live with the genetic material that our parents gave us; with the risks inherent in where and how we live, and with the realities that life is a fatal illness.  We also all deal with the challenges of living; supporting ourselves and our families, and making our way in an often hard, cruel, and still beautiful world on our personal journeys through life.  What this means is that medical interventions and interactions with health care professionals are unlikely to solve all the problems and life challenges that we often, unrealistically, look to medicine to solve. 

One of the real challenges in medicine is the attempt to tell the difference between a medical problem that can be solved by medical professionals and a problem manifested by physical symptoms that is really a life challenge that must be addressed by means other than medical tests, surgeries, and the latest in pharmaceuticals.  In many ways, the most difficult job in medicine is still the job of “triage” which in its broadest sense, is the ability to assess, or diagnose a person to determine if their symptoms can be helped by the tools and skills that medicine offers.  Since sickness and health are a continuum and there are often few clear lines as to where disease starts and ends the starting point is always the “eye of the beholder” or the belief that the patient in need brings to the appointment with the health professional. 

That belief usually is communicated as a problem presented by the patient, and referred to as the “chief complaint” with the plaintive question to the doctor of “what’s wrong?” and the expectation that the doctor will either wisely give an answer and a medication to fix “what’s wrong” or order tests to determine “what’s wrong’.  The unsatisfying, but often true answers, which doctors rarely give is “you are lonely” or “you are sad” or “you are fearful” or “you are overwhelmed by the problems in your life”.  Instead tests are ordered, a possible “virus” or other medical illness is referenced and a medication is prescribed. 

The fact that the mind and the body are connected and that both mind and body are intertwined with our own personal life environment (mind/body/environment connection) is not given enough attention.  People who present to their doctor, in pain, need care – they may or may not need medical intervention.  They may need care that is more directed towards their emotions and to the true life problems that are presenting as medical illness.  A single mother who has a young child in need of cardiac surgery and who also has three other children to take care of, feed, pick up from school and do all that needs to be done, in addition to needing to showing up at work, needs care when she presents with chest pain and muscle aches.  Chances are, the pain she has is more of a manifestation of her stress and her real human problems than of an impending heart attack.  But how do we know? 

Recently, much has been written about the doctor shortage and a recent blog commented by pointing out that more care does not necessarily mean more doctors.  The article points out how technology and the use of nurse practitioners and physician assistants will change the medical model and create new solutions to the doctor shortage.  While I agree with that assessment, I admit to worrying about the ability to use all these new models, and leverage other health professionals in ways that maximize the skills needed on that front end to determine if the problem is amenable to medical intervention.  I also am concerned that the resultant fragmentation from multiple professionals and multiple communication channels may impair the trust needed to help people in ways that truly address the mind/body/environment elements that are all necessary to care for people.  I worry about team based approaches devolving into bureaucratic confusion for the patient and a “pass the buck” mentality that is already seen in the interface between health benefits, access to care, primary care and specialty care in certain systems. 

Every patient should be assessed and treated with the following elements in mind:

  1. Assess and diagnose both the medical and the contextual (social and psychological) issues contributing to the problem
  2. If a medical intervention is needed, define a diagnosis plan and a treatment plan in partnership with the patient and consistent with the patient’s values and beliefs
  3. Define a care plan distinct from the medical intervention but coordinated with the medical intervention consistent with the patient’s values and beliefs, whether or not it is a medical disease which needs a medical intervention
  4. Define an action plan to ensure that both the medical intervention plan and the overall care plan are followed.
  5.  Identify the right professional with the right skills to implement the medical plan, whether that means surgery, a procedure, or medication management. 
  6. Identify the right professional to provide the needed encouragement and coordination needed to implement both the medical intervention plan and the care plan.
  7. Follow through relentlessly on both the medical intervention and the overall care plan as the bumps in the road can easily derail both.

To effectively accomplish these steps, you need skilled professionals and you need to gain and maintain the person’s trust that the medical treatment plan and the care plan as developed will help.  You need physician skills, nursing skills, social work skills, mental health skills and even insurance and benefits skills.  You need diagnostic acumen, cultural competency, communication skills, coordination skills and the skill to build and maintain a relationship.  While in the past, a physician was expected to have all of those skills, we now know that these skills are often best done by those with a myriad of different training, and can be facilitated with technology.  The real challenge, is how to put all this together, in a very simple way that fosters trust and involvement for all those in need of care.   The high level opinions on the need to leverage professional talent and technology must address exactly how this is accomplished so the person at the center of all this effort, actually benefits. 

As we think through all the pieces of this complex puzzle, let’s make sure that we focus on building trust, understanding an individual’s values, culture and beliefs, and accurately assessing their medical and their care needs.  We need to think through the best way to accomplish that in ways that are both effective and efficient.  We also need to think carefully about how to combine all the skills and professionals in a seamless, simple way.  Until we understand all that, I will continue to maintain my very traditional strong relationship with my primary care physician and pray that I stay healthy.  

Sunday, July 13, 2014

How I Spent My Summer Vacation and the French Paradox

I have just returned from a wonderful, enlightening and exhausting trip to the Brittany and Normandy regions of France.  The trip was centered on my second son’s wedding to a young woman from France.  This wedding in France included parents, relatives, friends and was carefully planned to be an amalgam of the French, American and Jewish traditions and cultures that their union represents.  The outdoor farmhouse setting in the French countryside, an hour from Nantes in the Brittany region on the border of the Loire Valley was extremely French as was the meal.  The marriage under the Chuppah, the traditional Jewish wedding canopy and the Jewish wedding vows were very Jewish.   The music incorporated a Klezmer band and a DJ playing standard American selections as well as French music.  It was a fascinating weekend and a very successful meeting of the different peoples and cultures. 

The wedding meal especially, was fascinating to me, as someone who cares about nutrition, health risks, and the cultural aspects of health.  It was eight courses (and please don’t ask me to remember and describe each course as the wine with the courses make that sort of memory impossible) and lasted six hours.  For those six hours, the music did not play and the focus was on eating, talking and enjoying each other’s company only interrupted by the occasional toast and the videos of the bride’s and the groom’s childhoods.  The French guests enjoyed every minute savoring each bit of food and the American guests couldn’t quite figure out what was going on.  The American mind set and frame of reference was one of eating rapidly and eating a large amount at times of joy, while the French mind set was one of savoring each bite, taking time with each course, and generally focusing on the taste of each unique food that was part of the admittedly small portions of each course by American standards but totally generous meal when measured in its entirety.  For the French, any one course that was too large would only hurt the enjoyment of the next course. 

While this meal was unique as a wedding meal should be, the manner in which it was eaten was fairly typical of what I observed during the rest of my and my wife’s travels through the villages, towns and cities of Brittany and Normandy.  A meal in any of these locations was an event to be savored, and enjoyed over time.  It was noticeable that this held true for everyone, not only the tourists and vacationers.  In most villages, stores would close for two hours in the middle of the day so that the storekeepers could take their lunch in the “correct” French way, slowly and focused on the quality of the meal that was being eaten.
The manner in which food is approached and eaten and the significance of the meal is clearly very different in France than in the United States.  One person I met who lived in the city of Bayeux, told me that his grandmother would spend at least five hours a day on food preparation and the remainder of the family time appeared to be related to conversation about food and upcoming meals.  Traditional French food uses a great deal of butter, cream and animal fat, and would be considered by US standards to be unhealthy however it is also very tied to natural ingredients and to the use of primary sources – sourced from local farms, bakers, and other food producers. 

Considering the high fat content of the food in France, the phenomenon of the “French paradox” has been well described for many years.  In an article in 2001 by Jean Ferrières entitled, “The French Paradox: lessons for other countries”, the author defines the paradox as the observation that coronary heart disease death rates are low in France despite high intake of dietary cholesterol and saturated fat.  There has been a great deal written on the reason for this paradox from the high red wine intake, to the complex behavior and attitudes towards food that I observed during my travels. 

There are those who argue that the French paradox does not exist at all and the differences seen are just a statistical aberration however proof of that contention has been difficult to elucidate.  Michael Pollan, in his book “In Defense of Food” published in 2008, suggests the French paradox is due to the nutrients found in “natural” foods as opposed to “processed” foods.  Pollan advocates an approach to food in general that culturally may have more similarities to the French way of eating than to the American norm. 

There is no simple answer to the paradox and it appears that many factors, including perhaps different statistical methods, all contribute.  Whatever the reason for the statistical paradox, I believe that the traditional French way of eating, with its focus on eating slowly, focusing on the taste of each bite and on the quality of the food instead of the quantity, has some role in the lower incidence of death from heart disease.  Smaller portions are the norm, and the ability to enjoy the eating experience, I believe, is a part of the answer.  French people I spoke with fear that this cultural approach to food is on the decline as the pace of life becomes more frenzied and more Americanized.  That is reflected in recent statistics on obesity increasing in France. 

If there is a lesson to be learned, it is the lesson that how you do something, such as eating, is often as important as or even more important than what you do.  You can eat food that appears to be less healthy but if you eat more slowly, eat smaller portions, and consider food intake to have a social dimension that does not allow the “eating on the run” and the mega-portions that are part of American life you are likely to be healthier. 

That is a lesson that extends beyond diet to all aspects of life.  As we discuss health care in general, and we focus on evidence based best practice and standardized care, we must stop and think about whether a singular focus on what we do, rather than how we do it, will hurt us in the long run.  For me, I return to the United States, having eaten my way through northern France, and weighing less than I did when I left for my trip, convinced that I will try to adjust my eating to be slower and more aware of what I eat, and perhaps to drink a bit more wine as well.  I will also adjust my thinking to stay focused on the “how” as well as the “what” in all aspects of life including my professional life in health care.