Wednesday, October 1, 2014

Communication as a Valued Skill in Patient Care: The Need for a New Profession.

The Curse of Knowledge.  We tend to think of knowledge as a positive attribute, and we are right, however every positive attribute has within it the challenge of the attribute being used correctly and sensitively.  In a recent commentary in the Wall Street Journal entitled “The Source of Bad Writing” Steve Pinker describes this curse, defined as a “difficulty in imagining what it is like for someone else not to know something that you know” as a source of much of the bad writing that we see.  He wrote:

“Anyone who wants to lift the curse of knowledge must first appreciate what a devilish curse it is. Like a drunk who is too impaired to realize that he is too impaired to drive, we do not notice the curse because the curse prevents us from noticing it….. I go to a website for a trusted-traveler program and have to decide whether to click on GOES, Nexus, GlobalEntry, Sentri, Flux or FAST—bureaucratic terms that mean nothing to me. My apartment is cluttered with gadgets that I can never remember how to use because of inscrutable buttons which may have to be held down for one, two or four seconds, sometimes two at a time, and which often do different things depending on invisible "modes" toggled by still other buttons. I'm sure it was perfectly clear to the engineers who designed it.”

While his message is about writing, it also applies to medicine and to the communication that is critical to good quality medical care.  Medicine is a field of endeavor in which sensitive topics require strong communication, however, the curse of knowledge has infected medicine through policies, regulations, economics and medical education. Medical professionals are trained to learn a highly specific language and we don't give doctors the time, training, and incentives to communicate. We also seem to be stuck in a destructive cycle in which the cost of giving physicians and other health professionals the time and tools they would need is assumed to be too expensive in our resource stretched world, so the problem keeps getting worse. However, while we act otherwise, it may actually be less expensive to give health professionals more time with patients because we often substitute tests, drugs, and procedures for communication.  Many of the concierge medical programs and the direct primary care approaches are starting to prove that the most expensive part of the health care bill is not necessarily the increased time per office visit. 

Giving doctors, nurses and therapists more money for more time, as the only solution, will not solve the problem.  I worry about the challenge of retraining doctors who have been taught that the communication aspect of treating patients is not important.  The current system is driven by an almost religious belief in science alone and dedicated to the precision of scientific language which is often incomprehensible to those who are not in medicine. We must try to change the culture in medicine and in medical teaching environments that lauds the medical scientist as the final arbiter of all that is high quality in medicine. That being said, the science is critical, and we should not be compelled in this cultural change to devalue the science. But we must regard the caring and the communication as being of equal value to the science.

I know this will be challenging. It is extremely difficult to change the culture of medical education in which physicians huddle outside patient rooms around computer screens, discussing among themselves the diagnostic dilemmas and the therapeutic challenges that the pathology, not the person, presents. It is also extremely difficult to change the insurance rules and payment systems and the culture of insurance, government and health policy which speaks in the language of "incentives" and "codes" and "adjudication", rather than the language of “caring” and “understanding.”  It is virtually impossible to change a medical science and industry infrastructure that looks for a complex medication or a new technology or a new payment methodology rather than looking for a better way to relate to people as people.

Yet we will not improve care and caring for people unless we start to focus as much on changing this culture of purist medical science to one that values communication, story telling, and the social and psychological aspects of people's lives.  We can learn lessons from Pinker’s message and from literature in general about communicating with people’s spirits as well as their minds.

Dr. Daniel Sulmasy, a Franciscan monk, physician, author and expert on medical ethics, has written extensively on the need to see the experience of illness as distinct from the disease pathology.  He wrote:

“Illness is a spiritual event. Illness grasps persons by the soul as well as by the body and disturbs both. Illness ineluctably raises troubling questions of a transcendent nature-questions about meaning, value, and relationship. These questions are spiritual. How health care professionals answer these questions for themselves will affect the way they help their patients struggle with these questions.”

It is spiritual, it is literary, it is story-telling and of course it is scientific. Health care touches people as people and not only as patients.  As such, we must find solutions that fosters the caring, the communication, and the literary and spiritual aspects of care as well as the purely medical science aspects. 

My solution is somewhat radical but also keeping with the tradition of medicine in human history.   A new health professional dedicated to hearing people's stories, relating the stories people tell to professionals in ways that influence the care they receive, and helping those people in need by translating the jargon of insurance, care delivery and medicine, into understandable and actionable prose that reflects their lives, their challenges, their values, and their fears. A profession that recognizes the spiritual nature of illness as well as the scientific aspects of disease.  We, at Accolade call the professional who has this communication expertise the Health Assistant and lest this blog seem too much like a shameless commercial, our goal is to create this new profession in addition to growing Accolade as a company. Of course I want to see the success of my company, but more as a vehicle for changing the landscape of medicine than as a purely commercial endeavor.  Our patients need and deserve this. We all, as people, need to be approached with a dedication to true communication that matches the dedication to medical science.