Tuesday, October 28, 2014

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way Part 4 – Impacting Emotions

“The good physician treats the disease; the great physician treats the patient who has the disease”
Dr. William Osler

We are all emotional beings.  Emotions are necessary and part of the human condition and are associated with illness of all types.  This is so self-apparent that people who lack certain components of emotions are considered to have a disease.  Whether someone lacks fear and tends to put themselves in danger or lacks empathy and tends to put others in danger, they are seen to be at a significant disadvantage in life.  Thus it is no surprise that people have emotional responses when they are in pain and when their body is overcome by changes due to disease.  These normal emotional responses to disease are actually helpful as we adjust in order to effectively deal with the challenge of being sick.  But while small doses of fear, anger, sadness, and other emotions are helpful, so too can they be destructive when they move into the realm of full blown depression, anxiety and denial that can signify a need for active treatment.  Even when the emotions do not reach that level of distress, they still must be acknowledged and addressed so that they do not lead to bad decision making when accessing care.  A person who is frightened can rush to an Emergency Room when waiting a day to see a primary care physician can be a better decision.  A person in denial can avoid needed immediate care and end up with severe consequences.  While neither situation may raise to the level of full blown emotional illness, they can adversely impact care. 

The interplay between medical illness and emotions has always been a part of medicine.  In recent years, with the emphasis on efficiency and adherence to disease protocols, the emotional aspect of treating illness has sometimes not garnered the attention it deserves when one visits a doctor or a hospital.  But a number of researchers have continued to look at the interplay between emotional illness and medical illness.   A classic article published in the New England Journal of Medicine in 2010 by Dr. Wayne Katon and his group showed that by combining support of chronic medical illnesses such as diabetes and heart disease with better treatment of depression and other behavioral diseases, clinical results were vastly improved.
Dr. Katon, with his work, coined the phrase “collaborative care” to describe a combined medical emotional approach to treating patients with illness and described three needed components to good collaborative care; a population approach driven by standard metrics for both the behavioral and the medical problems, monitoring of adherence by patients, and the use of “stepped care” or intensification of therapy if patients are not responding to therapy even when they are adhering to their treatment.  While poor adherence is often an issue in poor outcomes, a lack of proper monitoring and an inability to intensify therapy as needed are more likely to cause failures of treatment. 
At Accolade, we have made the use of collaborative emotional and medical support a cornerstone of all that we do to assist our clients.  In a commentary written in 2012 in the American Journal of Preventive Medicine, Dr. Katon cited the use of multi-condition managers to enhance quality of care.  At Accolade, we have used this type of model since we started helping people more than five years ago.  To quote his commentary:

“Several studies have expanded the concept of collaborative depression care by training care managers to enhance quality of care for depression and common comorbid conditions such as hypertension, diabetes, and coronary heart disease.  These new multicondition collaborative care models may provide economies of scale to treat multiple common primary care conditions.  Rather than primary care systems needing a separate care manager for each illness, which may be prohibitively expensive, multicondition care managers can provide enhanced quality of care for the most common medical conditions in a cost-effective manner.”

The key for us at Accolade is to expand that concept even further and recognize the patient as a person with medical, emotional, financial, spiritual and social needs.  We help the person address all those needs in a dynamic, ongoing way.  The data that shows that adherence and stepped-care are both important means that a relationship based case management approach is needed to remind about adherence and to maintain a patient’s trust so that if treatment is not effective, he or she can be coached and helped to return to the care giver in order to be properly assessed for intensified therapy.
While this results in improved care, the question is whether it saves money.  An article from the American Journal of Preventive Medicine by a group at the CDC suggest that the savings from this type of collaborative care approach can be significant.  By performing an in depth analysis of previous studies, they found that savings per person could reach levels of from $1,000 per person to $4,000 per person.  Their conclusion was that collaborative care provides good economic value. 

Saving money in health care paradoxically often means doing more, not less.  In the case of emotional reactions to illness, the need to proactively identify, monitor and treat the depression, anxiety and even the fear that is part of being sick results in higher quality and lower cost interventions.  This is one more example of Osler’s dictum that the great physician, and in our case the great health assistant, treats the person who has the disease.  This results in saving money in health care the right way.  

Thursday, October 16, 2014

Bias, Fear, and Health Care

Dr. Leana Wen is a wonderful physician and author (as well as a member of the Accolade Medical Advisory Board) who is a recognized expert on the role of communication in medical care.  In a talk she gave in May of this year at TedX Foggy Bottom, she spoke, for the first time, about her own experience as a stutterer and the paralyzing impact of the shame and fear that the stuttering caused.  Stuttering, for Dr. Wen, is just as important to her identity as her being Asian-American, being a woman, and being a physician.  It is part of the complex tapestry of who she is as a person and how she is seen by others and how she sees herself.  Each one of us is an amalgam of   traits, beliefs, attitudes and histories that defines us for the rest of the world and shapes our own perception of how we interact with the world.  This complex dynamic of the world’s perception of a person combined with a person’s own perception of what makes them unique can dramatically affect every aspect of our lives, including our health care.  In the latest issue of Health Affairs Dr. Wen builds upon her TedX talk and tells a story of a patient who is also a stutterer who initially receives sub-optimal care for chest pain due to his stuttering.  When the care is transferred to Dr. Wen who recognizes the trait and adjusts the evaluation and treatment accordingly he receives the right care. 

The way others see us and the way we see ourselves can create barriers to receiving the right care at the right time.  In the case that Dr. Wen describes, the first ER doctor saw the intelligent lawyer who stuttered, as someone who was slow, possibly even mentally impaired, and that created a risk that the care to be rendered could be misguided and wasteful.  Dr. Wen was called in to obtain blood tests and x-rays to evaluate the patient’s chest pain however when she was able to communicate with the patient in a trusting, caring way, he needed neither as the problem was not what it initially seemed to be.  Rather he had found himself in the ER with a diagnosis of chest pain due to his being in a situation in which his fear of stuttering created a panic attack.  The blood tests and x-rays were unnecessary and after his evaluation, he was able to go home.  It would have been no different if the issue was a language barrier, a manner of dress, or even someone’s race giving rise to bias. 

While bias in health professionals is a problem, it is only part of the problem.  Each of us also has a trait, belief, or other feature that cause us to feel fear and to block our ability to achieve all that we can achieve.  That fear can be related to race, family background, or physical disability.  It can be based in personal or historical reality or just be a perception that has no basis in anything overt or obvious.   I am a Jewish child of immigrants and while I take pride in that pedigree, when I was growing up, it also elicited a certain fear in me and led me, to sometimes feel as an outsider in the medical circles in which I worked and lived.  When I started medical school I had to get past the feeling that every one of my classmates was tall, with blond hair, had parents who were alumni physicians and had gone to Yale (since over 20 people in my class of about 150 at Columbia had gone to Yale it had a bit of a basis in reality).  Externally, when I was growing up, I faced some overt anti-Semitism and while not enough to be material, when combined with my family history of uncles and aunts being killed in the hell of Auschwitz, the fear that it elicited was very real.  My father, my hero, lived with a certain amount of fear that was founded on the reality he lived with when he was in Europe helping others escape from Germany and he passed some of that on to me.  He also passed along the bravery to stand up to the fear and take the kind of risks only an immigrant coming to a foreign land with nothing could take.  While that may seem disconnected from the stuttering that Dr. Wen describes, the fear that was part of my family history was a self-perception that sometimes caused me to be treated differently and to hold back when I should have been assertive.  It was my stuttering.  In a critical illness situation, that can be dangerous.

In health care, which is so personal, the external reality of bias for any reason, and the internal feelings of fear, can lead to care that is bad, dangerous and often more costly than it should be.  In May 2013, I wrote a blog post about my son’s hospitalization for a unknown illness, and the perception of the staff that his illness was not serious, or was somehow his own fault (the illness actually turned out to be secondary to an unusual disease totally missed by the staff at the teaching hospital).  The bias that they developed, just based on their assumption of who they thought he was hurt his care.  Happily, his own self-perception was strong enough, that he could overcome that barrier to get the right care at a different health system after discharge and be treated successfully.

The combination of health professionals who put a “label” on anyone, for any reason and the fear brought on by a self-label can be deadly, but they both can be fought.  A person, who recognizes the bias in a health professional, even if inadvertent, can point it out to the doctor, nurse or therapist and in most cases, the professional will probably apologize.  Thus the “disease” of bias, which affects care, can be countered, just as it was in the case related by Dr. Wen in the Health Affairs article.  If that doesn't work, then quietly demanding to be treated as an individual and not as a perception or a label may be needed.  Often the harder job is attempting to overcome the internal self-images that tell you, in a soft voice, that you cannot succeed so you don’t even try.  In those instances, just as Dr. Wen uses that self-image of being a stutterer to help her succeed, so others can be coached and supported to embrace who they are and to turn the fear into a strength.   In a person’s journey through illness, both the health professional and the patient have to be ready to face their own biases and their own perceptions head on to obtain the best care.  

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.