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.