Monday, March 23, 2015

Complexity for Doctors and Complexity for Patients

In a previous blog post following my attendance at the New York Conference Board’s 15th Annual Employee Healthcare Conference, I wrote about paradox and focus in healthcare.  The Conference Board, assisted by the consulting firm of Towers Watson, each year plans and sponsors this conference on the east coast, in New York, and on the west coast in San Diego.  I will not comment on all the east coast people who attended the meeting in San Diego except to say I am sure it had to do with some corporate and intellectual reasons rather than the winter the east coast has had this year and the setting overlooking the bay in San Diego.  The speakers were mostly the same in both venues and I attended both as a speaker.  As I flew back to my home in Atlanta from San Diego, I reread sections of one of my favorite books, “The Checklist Manifesto” by Dr. Atul Gawande, the Harvard surgeon and writer.  In his first chapter, he gives great insight into the root cause of the need for focus in healthcare that I wrote about previously. 

He notes that the average doctor seeing patients as an outpatient, over the course of a year evaluates an average of over 250 different   primary diseases and conditions.  He goes on to show that the clinical issues related to those 250 diseases and conditions are then multiplied to make for almost mind numbing complexity.  For that average doctor, patients had more than nine hundred other active medical problems that had to be taken into account.  That doctor in practice prescribed some three hundred medications ordered more than a hundred different types of laboratory tests and preformed an average of forty different kinds of office procedures – from vaccinations to setting fractures.   And that is purely for an office practice, rather than the intense needs of a patient in the hospital or undergoing surgery.  Even then, he points out that the most common diagnosis in the computer systems he went to in order to determine the scope of the problem, is “other” because it is so difficult to find, in the coding system computers use, the precise diagnosis or set of symptoms that you are dealing with for a particular patient.  In the intensive care unit of a hospital, the average person caring for a desperately ill patient has to perform on average 178 daily tasks and all must be done correctly.  Any one of those tasks done incorrectly has the potential to result in infection, cardiovascular collapse and death.  If anything, due to the coding systems that result in so many decision falling under “other” and the small critical tasks that are not captured in any computer system, we are understating the complexity and the sheer number of options for diagnosis and treatment that are available.  This creates the need for the focus I described previously.  For Dr. Gawande, one answer to this complexity, and the inevitable errors and omissions that occur due to the sheer mass of decision points is the focus that a checklist brings to good decision making. 

In every endeavor, including medicine, the discipline of a simple checklist can lead to powerful improvement in any complex task.  But let’s take a look at this complexity from the patient’s point of view. 

The patient, in our era of patient centered medical care is expected to be a full partner with their physician and nurse.  They must understand all of their options medically without the training, mentoring or experience that the health professionals have and are expected to understand those options in the few minutes a physician takes telling them the options.  But patients have more than their disease to think about when making their choices and their health decisions.  Life, with all its innate complexity even without disease, gets in the way of decisions and of the care itself.  A person, who becomes a patient, may be a single parent, living from paycheck to paycheck, caring for a child while also caring for an elderly parent with Alzheimer’s disease.  They may be in custody battles with their former spouse, may be involved in their church, and may be trying to look for a second job.  The person may be an immigrant for whom English is a second language.  They are likely to be sad, afraid and may be alone.  They may be struggling with other chronic illnesses. 

For patients, the multiple co-morbidities they may have and the symptoms they feel are impacted by the sadness and fear that are inherent in having an illness.  This sadness and fear can rise to the level of depression and clinical anxiety very quickly and need treatment decisions of their own.  Their competing responsibilities for family, work and other life requirements can be overwhelming when also trying to deal with something as simple as an upper respiratory infection let alone a cancer or a heart problem. They may have to factor in how to pay for the medications and treatments they need while also paying their rent and for food for their children.  The complexity that Dr. Gawande thus describes within medical practice is dwarfed by the complexity the patients have when they sitting in their living room rather than sitting across from the physician and the nurse.  I am not sure that there is any checklist that can address all these issues.

I have the privilege at Accolade of helping people as they deal with this life and health complexity.  I see people who are call center workers, field technicians, IT experts, and even senior executives struggle as they try to balance all that life throws at them.  While a checklist might help, they need a human touch to be with them as they find solutions that work for them. 

At Accolade, we use the principles of the checklist manifesto for those patients, even though the checklist is different for each person we serve.  We add to that checklist the caring and the ability to ensure that the person in need never feels alone.  Our checklist is always dynamic and changing and recognizes the challenges and strengths of the individual in need as they journey within the health care system.  We recognize that these decisions and choices do not occur in a health care vacuum but in the day to day crucible of life.