tag:blogger.com,1999:blog-41028110493522819542024-03-13T04:43:51.504-07:00Thoughts on Health, Wealth and LifeCommentary and opinion from Alan H. Spiro, M.D., M.B.A.Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.comBlogger181125tag:blogger.com,1999:blog-4102811049352281954.post-35722108102217870282019-09-18T07:34:00.001-07:002019-09-18T07:34:15.766-07:00The Central Myth of American Medicine<div dir="ltr" id="docs-internal-guid-313479e1-7fff-278e-39fa-77976b2bd25f" style="-webkit-text-size-adjust: auto; line-height: 1.2; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">In recent years, there has been significant progress in trying to predict future disease both by statistical and biological methods. The combination of genomics and artificial intelligence has proved to be quite powerful in moving us along a path that can drive better disease prediction. I spend most of my working hours with this effort driven by my assumption that early warning will lead to better interventions to fight disease and ultimately to better health. But I can’t be 100% sure. What if all those predictions only cause anxiety and confusion? I thought about this as I read an article in the </span><a href="https://www.wsj.com/articles/after-dorian-forecasters-ask-can-too-much-hurricane-data-be-a-bad-thing-11567961746?emailToken=d65c4751362c6c95ad0ad5bd020d1a16Su3wnoUnN1mb9/9Z1mqA6+8zaEJge1yqT/Er7WlGLulB1iUSP9LC6R1UltioGuwNkKthltyENZQnWlQZ8tha6HJfNkJKyZPE51LIH69nEdCrS/LY77CDt4IcmpNlmk8pkIfpxYk39kLvmYnMVJuluQ==&reflink=article_copyURL_share" style="text-decoration: none;"><span style="color: #0563c1; font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; text-decoration-skip: none; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">WSJ</span></a><span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;"> about too much messaging, coming too early dulling our reactions. This was in the context of storm prediction but similar principles apply in health and disease. Ultimately, with both storms and impending illnesses, the questions are all about what can be done to either prevent or at least mitigate the potential catastrophe. Do you want to be able to plan, to take medication to lower the risk, to change your lifestyle? Or will all that information just create anxiety, depression and contribute to a nihilistic type of fatalism?</span></div>
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<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">In the case of storm prediction, the article pointed out that “More accurate data gives more time for emergency planners and residents in a storm’s potential track to prepare. But the long lead-up also can result in saturation storm coverage and social media hype that leads some people to tune out.”</span></div>
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<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">It goes on to note that “continual storm coverage was a source of annoyance for many and led to fatigue for some, adding to concerns that information overload would lead them to miss key communications.” The earlier the information is obtained and given, the more likely it is for the information to inform, but also the more likely the information will ultimately be wrong. Time is an important variable, and it has a habit of changing things in the weather as in life. </span></div>
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<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">Health plans, health systems, private companies, and government are all using huge data bases of claims, medical records, genetic data, and anything else they can find to create algorithms or formulas which can predict our future health. These efforts are having some success, and as someone who works in this area, I expect our abilities to increase. But will we actually be helping by predicting? Will we be contributing to an unhealthy focus on disease prevention instead of healthy living or to a numbing of a message that change is needed?</span></div>
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<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">The questions we are attempting to answer almost appear to have a biblical quality….Who shall live, and who shall die? Who shall be infirm and who shall be healthy? I am Jewish and will be stating words very similar to these in the Rosh Hashana and Yom Kippur services which are around the corner. We say this as we pray for forgiveness and hope that in the coming year we will be blessed with health and happiness. It does seem almost God-like to be able to predict in this way. But it’s important to remember that our predictions are never 100% accurate, and that even if they are, we don’t really know if the predictions will help or not.</span></div>
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<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">The optimists among us believe that these predictions will allow us to intervene and help prevent the diseases before they appear. The pharmaceutical companies believe that they can develop medications to forestall and prevent diseases before the illnesses express themselves to the detriment of the patient. Those in the wellness fields believe that changing lifestyles will forestall the “ultimate decree,” as is said in the prayer book for the High Holiday services. </span></div>
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<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">But we don’t really know, and we also don’t know if we will just be creating undue anxiety and depression. We don’t know if we will contribute to information overload that does not really help those we hope to impact most. We don’t know if our new medications and our new approaches to intervention will ultimately lead to unintended consequences that may be harmful. </span></div>
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<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">We don’t even know how much people want to know. We do have experience of a sort from the testing for genetic diseases that offer people some predictability. Huntington’s Disease is a genetic illness and was one of the first genetic diseases for which there was a definitive test to see if someone was a carrier, or likely to have the disease. It is a disease in which brain cells are killed and which leads to death. Since we can identify people who will likely develop the disease, it is informative to see how often people want to know. A review from the </span><a href="https://jnnp.bmj.com/content/69/5/574" style="text-decoration: none;"><span style="color: #0563c1; font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; text-decoration-skip: none; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">BMJ</span></a><span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;"> showed that only 10 to 20% of those people at risk for Huntington’s Disease end up being tested after being approached and offered genetic testing. The other 80-90% prefer not to know. </span></div>
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<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">Perhaps they are right. After all, life is not about avoiding illness. Rather it is about enjoying your time on earth and making a difference to those around you. While health is a central element, it is not the only element. Living your life with a focus on avoiding disease may be the right decision for some, but for others that focus on disease may prevent them from focusing on family and friends. </span></div>
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<span style="font-family: Calibri; font-size: 11pt; font-variant-east-asian: normal; font-variant-ligatures: normal; font-variant-position: normal; vertical-align: baseline; white-space: pre-wrap;">All that is not to say our prediction efforts and our attempts to decrease health risk should stop. It certainly is a big part of what I do every day and I am proud of my own work and believe it can improve people’s lives. All this brings me back to the title of this blog post. The central myth of American medicine is that Death is Optional. It is not. Life is a fatal disease. I for one believe that the efforts to predict disease must be tempered by the knowledge that we must use predictions to help people live the lives that they want to live until the moment they die and allow the focus to be on living rather than disease prevention at any price. I question whether the desire to tell everyone everything about the future may end up making us sicker than we started. </span></div>
<br style="-webkit-text-size-adjust: auto;" /><br style="-webkit-text-size-adjust: auto;" /><br style="-webkit-text-size-adjust: auto;" />Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-45633934278091513412019-09-08T15:18:00.003-07:002019-09-08T15:18:34.728-07:00Tracking Hurricanes and Predicting IllnessAs I watched the slow moving disaster known as Hurricane Dorian this past Labor Day weekend, it struck me that the prediction models for both the direction and strength of the hurricane kept changing. The striking fact that was clear as I sat in the safety of my Chicago condo, was how hard it is to predict exactly where a hurricane will go and how strong it will be. Different models had it originally heading across Florida into the gulf and later models were constantly being adjusted and changed. Eventually, it hit the Bahamas, made a hard right turn, and it did not hit the American mainland until it meandered up the eastern seaboard to North Carolina. An article in the <a href="https://www.wsj.com/articles/why-hurricane-dorian-is-so-hard-to-track-11567303949">Wall Street Journal</a> about difficult in creating the predictions quoted Matt Lanza, managing editor of <a href="https://spacecityweather.com/">Space City Weather</a>, as stating, “I’m constantly amazed at what just one tiny change can do to the whole picture.”<br />
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I understand. I have spent a good deal of time and effort leading a group of very smart data scientists, clinical informaticists, health economists and statisticians in developing algorithms to predict the “path” of illness in order to better intercept and intervene before disaster hits. We have the advantage of using the largest commercial claims data base in the US and possibly in the world, with over 40 million people per year. It is also possibly the most up to date health care claims database, as it is refreshed monthly, and the database with the greatest claims history, as it reflects 10 years of claims.<br />
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Yet even then, it is very difficult because “one tiny change” can have a dramatic impact. Medicine and health care are filled with low probability and high consequence events. Life is as well. Recently, we have been working on a model to predict people who are likely to be sick enough to generate $250,000 in claims in the coming 12 months. It means predicting any illness, all of which have different profiles, and different patterns that lead up to catastrophe. Thus, there are many numerous variables to predict numerous disease and combinations of diseases. This creates a data science problem that belies an easy solution. It means identifying someone who will be one of the 1 in 7,000 people to be sick enough to generate $250,000 in costs. The nature of the prediction challenge is also to identify those who are likely to have an illness that we can impact with proper treatment and/or proper support to improve the outcome. A missed prediction could mean a person has a much worse outcome, even death or disability. A personal “hurricane” that one may not be able to withstand.<br />
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The data that one uses must also include all factors that are present when a person becomes ill. That means including data on emotions, social factors, finance and culture, among others. If someone you love is in an accident and you are speeding while distracted while going to the hospital, you are more likely to have an accident. That is a data point that medical records or health care claims will not reflect. If you have just been fired from your job, that is another datapoint. If you are poor and/or lonely, these are extremely important factors in trying to predict illness. It is not just biology.<br />
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But biology is the central pathway, and claims databases, while reflecting medical care and medical interventions and encounters, are basically financial databases. Electronic medical records, genomic information, and social information must be integrated into co-mingled databases to make analysis and, more specifically, prediction more powerful.<br />
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With healthcare, as opposed to hurricanes, there are issues of privacy and confidentiality that bring legal and ethical issues into play when combining data. Dorian does not care if we know the details of its hurricane force winds but Jane Smith might care a lot that we are using her genetic information, combining it with her financial profile, any police record, her family dynamics, her friends and her spirituality to try and predict any illnesses and healthcare needs.<br />
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All these data feeds help us to become more accurate, but even if the privacy concerns are overcome, there will always be uncertainty. Progress will increase with each new insight, but someone can always trip in their own home and break an arm.<br />
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With each new insight we gain more predictability. Recently, in trying to predict patients who are likely to have very high costs due to critical illness, we found that the “velocity” of their medical activities was a useful variable in building our models. To calculate this requires a different algorithm to feed the algorithm.<br />
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In other work I am doing, we have found that knowledge of the genetic makeup of the bacteria that are in a normal human intestinal tract, part of the microbiome, can help predict things like sensitivity to medications, propensity to diabetes depending on diet, and disease activity in someone with Inflammatory Bowel Disease. Thus, the microbiome data has become an important variable in predicting disease.<br />
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And yet, our society demands perfection and immediacy. In another article about forecasting the path of a hurricane, it was pointed out that forecasts tend to define a forecast cone. The forecast cones have gotten significantly more narrow in the last ten years due to better measures and techniques, but there is still a 1 in 3 chance that the hurricane will be outside the cone completely. That is far from perfection.<br />
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I believe that in healthcare, it will be no different. We will make progress and get better with our predictions, but we must always remember that there will always be uncertainty in medicine. We will need to better differentiate between the need for huge databases, such as the one used by my team, and the deep data that will come from more knowledge of the individual, and how the the two will interact. In a future post, I will talk more about big data and deep data and how they both must be used. Ultimately, there will always be some uncertainty, but we can decrease it incrementally in our quest to improve care.<br />
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Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-12407518397739821442019-09-08T14:49:00.001-07:002019-09-08T14:49:11.868-07:00Restarting - It Appears I Have More to SayI have taken a hiatus of a few years from writing these thoughts, opinions, and occasional facts about health care, health economics and health benefits. The hiatus came from a lack of time, a shift in my focus, and a need to rethink my reasons for writing.<br />
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During this writing lull, I have continued to fight for approaches to health care that are data driven and humanistic. I have continued to fight entrenched ways of doing things, the use of health care for political means, and the decisions made based on poor judgement, faulty data, and over reliance on blunt instruments. I have continued to fight organizations that make decisions based on protecting their own positions and organizations rather than understanding and addressing the needs of people who are suffering.<br />
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I have seen health care attorneys look at all health care through the lens of the contract, health care data scientists look at all health care as new data algorithms to be developed, and internet entrepreneurs look at health care as their latest app. With all this, I have also seen physicians move from being independent patient advocates to being shift workers paid by large systems whose goals sometimes seem to be more focused on margins and growth than on caring for those in need. I have seen ego and wealth generation driving decisions instead of healing those in pain. I have also seen brave, caring professionals who get up every day to fight for the patient. I see those people getting tired and beaten down by the system in ways that are sad to watch.<br />
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So I will start again to put down my thoughts and observations in writing for anyone who cares to read them. My first blog post will be posted shortly, and I thank those who do take the time to read it.<br />
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Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-5224110879787201572016-06-30T17:15:00.003-07:002016-06-30T17:15:39.207-07:00Healthcare, Humanism and the Humanities<div class="MsoNormal" style="line-height: 18.85pt; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="color: #383838; font-family: "Helvetica","sans-serif"; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";">I am returning from a
prolonged trip in France visiting my son, daughter-in-law and nine month old
granddaughter followed by a few days in Amsterdam. In many ways, the trip has
been an emotional journey more than anything else as my wife and I were able to
hug, and play with Hannah, our French-American grandchild. <o:p></o:p></span></div>
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<span style="color: #383838; font-family: "Helvetica","sans-serif"; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";">That trip was all
about emotions, history, art, and family.
It was about different cultures and traversing lands with different
languages. In the glow of that trip, I
can't help making some observations on health care. I ask myself whether, in a humanistic endeavor
such as health care, do we leave out, or under emphasize those aspects of life
I focused on during my trip. <o:p></o:p></span></div>
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<span style="color: #383838; font-family: "Helvetica","sans-serif"; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";">In France, I lived
with my son and found myself in the rhythm of French life. It is a life that
reflects French culture and values which appears at first glance to be focused
more on the everyday than the goal oriented life that I see in the United
States. There is a saying that people in
the US live to work and people in Europe work to live and I wonder if there is
a kernel of truth to that. Just to clarify, I am speaking of small town France
and not the frenzied Paris life that is similar in major cities worldwide. One
can find a closer parallel in small town America than one can probably find in
Paris to my French trip. There appears
to be, in the tradition of Rousseau, great value given to the logic of a
balanced life. As Rousseau said, "Happiness: a good bank account, a good
cook and a good digestion."<o:p></o:p></span></div>
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<span style="color: #383838; font-family: "Helvetica","sans-serif"; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";">Our life there took on
a certain rhythm that did revolve around our meals. This is especially meaningful to me as a
gastroenterologist and expert in nutrition. Meals were savored over time with
real focus on the food; stores closed midday so storekeepers could enjoy their
own long lunches; walks were taken slowly after lunch. It took a while for me
and my wife to get comfortable walking slowly.
In many ways, what we now call mindfulness seemed to be part of my son’s
family, and my daughter-in-law’s extended French family daily living. Of course
people work and are productive and have all the worries that people all over
the world have. The attitudes towards
those needs appear to be different. We
would stop in the afternoon at a cafe to give our granddaughter a snack as we
sipped wine and watched nature, people and the world around us. History was all
around us as these buildings we sat in could have been built in the 1600s.or
1700s. I returned feeling like I had
done nothing but eat and found that I had lost weight. (I discussed this after a previous trip to France
in a blog entitled “<a href="http://healthwealthandlife.blogspot.com/2014/07/how-i-spent-my-summer-vacation-and.html">How
I Spent My Summer Vacation and the French Paradox</a>”). <o:p></o:p></span></div>
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<span style="color: #383838; font-family: "Helvetica","sans-serif"; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";">On our stop in
Amsterdam on our way back home, we went to the Van Gogh museum and I was struck
by all the medical aspects of his work and his history. The painting “Two Hands” that show working hands
that are thick from manual labor but also seem to have some contractures that
may be indicative of arthritis show the intermingling of life and work. His “Head of a Skeleton with a Burning
Cigarette” should be used in programs to stop smoking. <o:p></o:p></span></div>
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<span style="color: #383838; font-family: "Helvetica","sans-serif"; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";">What I am describing,
in an academic sense may be seen to be part of cultural anthropology, art
history, sociology, philosophy, and history. Throw in a dose of academic
French, enology for all the wine we had and a bit of high level culinary art
and it became apparent that our experience in France and Amsterdam can be intellectually
understood from study of the humanities rather than just, for example, from geography.
Just as one cannot interpret a trip such as ours as being only about geography,
one cannot interpret a trip to the doctor to be only about biology. <o:p></o:p></span></div>
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<span style="color: #383838; font-family: "Helvetica","sans-serif"; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";">Life is all about
balance and good medical care is all about life. It is not only science. Our health professionals should be well
versed in disciplines that help them understand that balance. That may mean more use of literature and more
instruction in psychology, sociology and anthropology. I don’t have an answer of a specific
curriculum to recommend. I only know
that we must do all that we can to prevent our medical and nursing education
from driving the humanity out of the talented people who choose those paths. <o:p></o:p></span></div>
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<span style="color: #383838; font-family: "Helvetica","sans-serif"; font-size: 10.5pt; mso-fareast-font-family: "Times New Roman";">There is a concept
that is reflected in a number of sources, most notably the Zohar, the Jewish
book of mysticism, which states that evil occurs when there is an imbalance
between love, wisdom, justice and glory.
In some ways, the science of
medicine often reflects the justice and the glory. The evidence based algorithms and those in
medicine who believe that they have all the answers to the dilemmas of health
care produce a certain regimentation which creates a framework for justice and
the entrepreneurial and the academic aspects of health are often driven by
those in search of the glory. While
individuals have tremendous love and wisdom, it may not be built into the
system to the degree needed to prevent a system designed for good from having
evil elements. I remain optimistic that
movements such as the Narrative in Medicine movement which stresses the
importance of storytelling as part of medicine will take hold and be important
in the education of health professionals. In order to have that
happen, we need to bring more humanities into the teaching of medicine and nursing. After all, we want the health professionals
who will be at one point or another caring for all of us to be holistic caring people who understand the impact the illness has on our life as
well as an understanding of the illness itself. <o:p></o:p></span></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-63692827596662373782016-06-02T05:19:00.001-07:002016-06-02T05:19:51.326-07:00The Balancing Act of Health Care<div class="MsoNormal">
Closing one chapter and opening another is an opportunity
for reflection. I have used the two
months since I last wrote a post to determine how I can continue to have an
impact on health care, while having the most fun as my work and life journey
continues. That has created more
questions than answers and more shades of grey rather than sharp lines of
clarity. However that is good. I have always believed that questions are
more important than answers and that those with perfect clarity about a
situation just do not understand the situation well enough. <o:p></o:p></div>
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So it is with health care.
Health care is filled with questions, with difficult choices and with
confusion for patients, for health professionals and for health policy experts
who want a neat and clean answer to our system challenges. In other words, health care is a terrific
reflection of the human condition and must be seen as a part of the complexity
of life. While the understanding of
human physiology and pathology may one day be totally answered by science and
amenable to computer generated algorithms (although I doubt even that), health
care has always been about more than biology.
Emotions, social interactions, finance, culture, communication,
spirituality all are part of health care and they don’t all follow simple biological
rules. Even the biological sciences obey
the old saw that the greater the knowledge of a topic the more unknowns that
surface. Good scientific answers tend to
elicit new and more questions rather than simply settle old questions. An economics joke is told by doctoral
students (mentioned in a Bloomberg Business Week article) that the questions on the doctoral exams haven’t changed in 50 years
but the answers have. The same can be
said of medicine. In health policy debates
we often hear the term “scientific fact” however the true scientist, including
the true medical scientist, knows that “facts” are never written in stone and
that the teachings of today tend to be proven false tomorrow. <o:p></o:p></div>
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<br /></div>
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Since health policy is involved with politics, and politics thrives
on simple answers and sound bites, it is no surprise that in health care policy,
there are always those who claim to have the magic bullet – the answer –
usually based on scientific fact. That
solution is often manifested as new laws and rules to address high costs, inequalities,
lack of access to care, and potentially poor quality care. However they may not address the constant
trade offs we must make as we deal with the need for access to good care for all
and the need for individual autonomy, individual respect, and customized
solutions based on the person and their unique situation. As Isaiah Berlin has said, “Liberty for
wolves is death to lambs.” We may
produce liberty and equity and not pay attention to the lambs that are being
eaten by the system. New regulations and
laws may also have the effect of pushing professionals to focus more on proving
one is following the rules than encouraging those professionals to actually
care for those who are in need. <o:p></o:p></div>
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In this spirit, I have my own “top ten list” of unanswerable
questions related to my life’s work of improving access to quality care. They include:</div>
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</div>
<ol>
<li>How do we fit the black and white
of contracts, legislation and regulations into the shades of gray that good
medical care requires?</li>
<li>How do we balance the needs of a
population and a community with the needs of unique individuals within that
community? As an example, how do we make
the choice between the cost of care for a healthy 95 year old that may benefit
from complex surgery and the thousands of children who could be immunized using
those funds? (I believe we can and must support both). </li>
<li>How do we address the fact that
human physiology is the same around the world however the non-biological
factors that make medical care more than biology vary immensely from country to
country, state to state, community to community and even person to person? </li>
<li>How do we create efficient systems
and smart systems that can assist health professionals while encouraging them
to keep their focus on the individual patient and not the computer screen?</li>
<li>When we speak of outcomes and
quality, from whose point of view are we looking? Is it the patient, the family, the doctor,
the system or the population? Often
outcomes and quality are in the eye of the beholder. </li>
<li>How do we monitor care to ensure
it is high quality while also allowing for the modifications of care depending
on the life context and the unique situations of the person in need? </li>
<li>How do we build systems that allow
for innovation, even with individual patients, but still protect patients from
being subject to experimentation and poor care?</li>
<li>How do we encourage good health
habits while not creating a system that punishes those who do not follow those
habits? </li>
<li>How do we prevent care equity
becoming poor quality, least common denominator care for all?</li>
<li>How do we acknowledge health care
as a spiritual and social need and not only a biological one? </li>
</ol>
<br />
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<o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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<o:p></o:p></div>
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These questions and others like them offer opportunities to
continuously fine tune and change our approach to the problems based on the
specific community, the specific patient, the specifics of the health care
resources that are available, and the times we live in. We must have systems and laws however our
systems must be flexible enough and smart enough, supported by smart caring
professionals, to address all of these dilemmas. We are in a constant balancing act trying to
make hard choices and doomed to never reach perfection. However our attempts to try to be perfect will
lead to better care for all. We must
recognize that arrogance is the enemy, humility is needed and questions may not
have a “right” answer. <o:p></o:p></div>
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<br />
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The processes we build and the regulations we put in place
impact populations and individuals who may not be in the center of the bell
curve but off to one side. All systems
and rules produce unintended and potentially negative consequences for those
people who do not fit neatly into the norm and the processes must allow for a
mass customization to address those atypical people, who may in aggregate be the
majority of patients. In dealing with
life and death health care decisions, care and sensitivity to the patients,
their families, and the health professionals manning the front lines of health
care must be emphasized and our systems must not only allow for that care and
sensitivity but encourage it. I, for
one, am excited to be on this journey even as I know that my solution today may
need to be changed tomorrow. Such is the
nature of health care and of life. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-7779005474183165932016-03-28T04:39:00.001-07:002016-03-28T04:39:14.488-07:00Moving On<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">For the past nine years, I have been involved in building a
company, Accolade, dedicated to experiencing the health care journey through
the eyes of each unique individual and family who are in need. Starting with a one room office, and a small
team led by Tom Spann, our CEO, we spent years finding solutions to the
problems inherent in experiencing illness in an attempt to make that journey as
simple, and as stress free as humanly possible – all that with the knowledge
that there is no more stressful time than when you or a family member is
ill. In addition to medical and
insurance knowledge, we brought into the equation information on decision
science, the psychology of persuasion and behavioral economics and created a
coherent set of processes that we could manage while making it seem to the
people we helped as if it were effortless.
We created simplicity during extremely complex and emotional times for
people. This took immense work and
creativity as there is no more difficult task than creating simplicity out of
the chaos that is often experienced when ill.
It meant rethinking how to engage people and how to create the type of
trust that allows the right type of help to be offered and to be accepted. It meant understanding a person’s need for
autonomy and to be seen as unique rather than as a disease or a
demographic. It meant understanding that
the experience of being sick is more than biology and insurance benefits but is
also emotional, social, financial and even spiritual. It is intensely personal for each person
affected and our methods and procedures had to find commonalities while
recognizing the segment of one that each person is. <o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Ultimately we created a new profession – the profession of
Health Assistant and the internal mechanisms to support that profession. The Health Assistant has to be an expert
problem solver, a relationship builder and to be conversant in the language of
medicine, finance, social work and insurance benefits. He or she has to be team oriented in order to
pull in their expert colleagues, whether nurses, doctors, psychologists,
pharmacists, social workers, insurance experts or even attorneys when needed
for a particular issue. The
communication links and the information have to be at each Health Assistant’s
fingertips in real time in order to keep it simple, real and humanistic. It can’t be scripted or too rote but it must
be performed with a certain rigor that is behavioral and scientifically based
and consistent across health assistants.
It must follow process but not be a slave to process. <o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">We started out with the belief that this service would not
only help and delight people, but it would save money in aggregate. Taking the fear out of so many decisions that
drive people to ask for unnecessary tests and services and helping influence
people towards the right care seemed to us to have the potential to save money
while doing the right thing for those in need.
We proved that to be true as well.
Time and again, when we studied populations with pilot populations
versus control populations, keeping everything else the same, savings were
documented that exceeded even our initial hopes. There were even indications of improved
quality of care from decreased readmissions, increased medication compliance
and increased use of preventive care. At
one point, one of our esteemed Board of Directors said, “You guys have
discovered penicillin!” <o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Those types of results do bring growth. Accolade is now a company of over 700 people
with three offices around the country and continues to grow. A new CEO has been named and a new team is
being put in place to bring Accolade to the next level of growth. As such, I am taking my leave but remaining
as a shareholder, an advisor and a supporter.
<o:p></o:p></span></div>
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<span style="font-size: 11pt; line-height: 115%;"><span style="font-family: Arial, Helvetica, sans-serif;">So I move on to my next chapter. I remain a strong believer in the ability of
health plans, physicians, nurses, health systems and all components of health
care to better organize in order to create more support and simplicity for both
the patient, the family and the dedicated physicians, nurses and other health
professionals who serve them. I will
continue to focus my career on finding solutions that achieve lower costs and
better access while removing administrative and other barriers for both patient
and health professional. I have always
done so with the strong belief that each person is unique and must be treated
as such and have found that with respect for all involved the best results can
be realized. I will now leave the growth
of Accolade to others, knowing that the foundation is strong and the principles,
processes and systems we implemented and tested have been proven to be
effective and look for my next opportunity to change health care for the
better. </span></span>Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-40064902040842581862016-02-16T05:04:00.001-08:002016-02-16T05:04:12.132-08:00What Does the Patient/Consumer/Beneficiary/Person (pick your word) Care about when Accessing Care?<div class="MsoNormal">
A <a href="http://www.accolade.com/consumerhealthcareindex">new
survey commissioned by Accolade</a> (I am Chief Medical Officer and a founder
of Accolade) performed by Harris Interactive (the Harris Poll people) attempts
to answer that question. From a medical
vantage point, it may seem like a simple, obvious question. The person
accessing care wants to get better! However,
the answer is much more complex. People,
when ill, tend to worry about more than those aches, pains and other
symptoms. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
The title asks one question but implies a second question. What does the person care about is the first. The second is whether the person accessing
care is a “patient” a “consumer,” a “beneficiary,” or some combination of all
of those? While physicians and nurses
clearly prefer to see those in need as patients, the most used and perhaps
overused term in the health industry these days is consumer. This often appears to be aspirational as
programs and companies are formed to try and find the magic formula with which
to induce patients to purchase health case as if it were any other consumer
item. I question whether the emotional
nature of illness, and the impact created by the potential for catastrophe
inherent in medical issues will ever allow the patient to truly be a consumer. “Consumers” traditionally are focused on cost
and feature comparisons such as deciding whether to get leather seats in a new
car. I don’t believe that when you or
someone you love is ill, you ever are a true consumer as implied by that
example. However, at the same time
patients are rarely if ever <i>only</i>
worried about the cure which use of the term patient may imply. They are worried about their family, their
finances and how their illness will affect all aspects of their life. People,
therefore must be helped to understand the value potential in each health
service and see clearly how those services relate to their life issues. That may fit into the term “consumer” even
more than it does into the term “patient.” <o:p></o:p></div>
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<br /></div>
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I date myself a bit by using the term “beneficiary” as this
is the traditional way insurance companies have described those who enroll in
their health plans. I rarely hear that
term used in today’s world. “Consumer”
has replaced “beneficiary” except in legal documents. People “benefit” from the access to care and
the financial security that health insurance and health plans offer hence the
term beneficiary. Fundamentally beneficiary
communicates the ability to gain access to care and to guard against financial
catastrophe rather than reflect the care itself or guard against medical
catastrophe. <o:p></o:p></div>
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<br /></div>
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I admit to struggling
with the right word to use as I jump between the different but co-dependent
worlds of health care delivery, health benefits, and the business of health. For the person in need, the distinction
between these worlds means very little and actually just reflects some of the
challenges of obtaining needed care in today’s world. This is reflected in this survey. It asks questions that approach the issues
with the knowledge that each respondent is a complex person with multiple
concerns that overlap into all these areas.
<o:p></o:p></div>
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<br /></div>
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The Accolade Consumer Healthcare Experience Index Poll surveyed
2.046 adults over the age of 18 of whom 1,536 have health insurance through
their employer, private insurance or Medicare.
What was clear from the poll is that the experience of accessing care is
seen as a daunting task for those in need.
While they trust their physician for health information with 74% saying
that they prefer to get information from their physician, they are frustrated
by a lack of coordination and challenged by the benefits rules and the
costs. Overall, 53% stated that the
hassle of “understanding what care will cost me” and “coordinating all aspects
of care” was the major problem that they faced when ill. It is interesting how strong the fear of
these issues is, even perhaps surpassing the simple question of getting
accurate diagnosis and treatment. <o:p></o:p></div>
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67% of those surveyed said that they wanted their health
care providers to understand their life circumstances more in order to address
their illnesses in a better way. People
understand, perhaps even more than many health professionals that coping with
an illness while coping with all the challenges of everyday life are
intertwined. The idea of a physician treating
a disease without good knowledge of their other needs and responsibilities
whether they are related to work, family or finance is a source of
frustration. 80% told the surveyors that
they would want a single person to trust to be with them and help them navigate
the systems and navigate the challenges of their lives when they require care
and they appear to recognize that person is not likely to be their physician. These numbers reflect a widespread concern
with the impact the disease has on a person’s life and family and not only a
concern with the biology of the illness.</div>
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<o:p></o:p></div>
<br />
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Much of this comports with ideas a group of us had some nine
years ago when we, led by Tom Spann as founding CEO started dreaming of a
better way to help people through the health care system and the health
benefits system. We had to rethink the
consumer and the patient and the beneficiary and think about how to create not
just a company, but a new profession, that of Health Assistant, supported by
the right information technology and the right management systems. The Health Assistant has to be part insurance
expert, part social worker, part financial advisor, part coordinator, part
health educator and most importantly a trusted friend. While training and experience is needed,
equally important are the management processes, the right content that is
always kept up to date on the technology platform, the right pay structures and
metrics for the Health Assistants, and a sense of purpose and responsibility towards
those being helped. The technology has
to support and drive all of those functions while avoiding the trend to become
a checklist that harms the human interaction that is core to the function. We have done that. We have proved that we can help people in a
very positive way and help the health care system as well with our approach. Data
from this poll only confirms our initial dream and makes us want to work even
harder to continuously improve our systems, training and approach in order to bring
this type of support to everyone. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-90427715400535382742016-02-12T12:37:00.001-08:002016-02-12T12:37:56.570-08:00The Place of Passion in the Business of Health Care<div class="MsoNormal">
I learned early in my business career, after being in
medical practice that the way business people and medical people communicate is
very different. Besides having
fundamentally different languages, clinical people tend to be more emotional in
their approach to communication than people in the business world. Sometimes clinicians can get a bit too
emotional as they take the passion and concern that is needed when helping a
sick patient into the business meeting.
On the opposite end of the spectrum are business people who are often in
health care due to their profound desire to help others. They can bring a hard-nosed focus on budget
and margin and sometimes appear to be uncaring of the human impact of those
numbers despite their commitment to helping.
Both sides have to understand and accommodate the emotional communication
style of the other if our current health care world in which business,
management and care are all intermingled has any hope to achieve higher quality
and lower costs. </div>
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<o:p></o:p></div>
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Physicians and nurses know that passion is helpful when
speaking with patients. The patients and
their families want to know you care, and that you share their sadness, their
anger and their fear as they enter evaluation and therapy for problems large
and small. At the same time, the patient
wants to feel that the health professional caring for them is the rock they can
lean on and not be overly emotional. The
gifted doctor communicates emotions without inflaming them and is able to walk
the difficult line of sharing sadness and happiness while also appearing objective
and professional.</div>
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<o:p></o:p></div>
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In the board room and in business meetings, physician often
feel the need to communicate the emotions of the patients to the managers in
order to underline the importance of the business decisions on patients’
lives. In this way, physicians often
feel when working with business people and managers that they must play the
role of emotional middle-men (and women) communicating the patient feelings and
reactions to the business professionals.
<o:p></o:p></div>
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In the business world however, the emotional speaker may be
discounted and de-emphasized in the internal negotiating that often reflects
productive business decision-making. That
emotionality may be thought of as reflective of less than fully rational deliberations
and the one displaying the emotion may therefore be less credible than the one
who can make a “business case” in a totally dispassionate way. There is often a belief in business and
management that rational analysis is inherently devoid of emotions. <o:p></o:p></div>
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In the past few years, research on decision making and
emotions have led to what Jennifer Lerner, one of the leading lights in this
field (Prof Lerner is an advisor to Accolade), calls a “revolution” with the
“potential to create a paradigm shift in decision theories.” In <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-psych-010213-115043">an
article published in the Annual Review of Psychology</a>, she and her
colleagues write, “emotions constitute potent, pervasive, predictable,
sometimes harmful and sometimes beneficial drivers of decision making.” While anger and fear tend to be thought of as
impairing good decisions, even these types of emotions in the right situations can
be useful. In the preface to his book, <a href="http://www.amazon.com/Feeling-Smart-Emotions-Rational-Think/dp/1610394909">“Feeling
Smart,” Eyal Winter</a> cites a study that shows when we are moderately angry
our ability to distinguish between relevant and irrelevant claims in disputed
issues is sharpened. <o:p></o:p></div>
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At Accolade, in our early formative years, I sometimes took
on the role of playing a difficult person calling Accolade with medical
problems as part of our certification of new personnel. During one of these certification calls, I
played an unpleasant person, who was angry at everything. The person I was testing, a talented business
health professional was accurate, dispassionate and correct in everything he
was saying. In my role as the patient
with the problems, his professional attitude made my character more angry as it made me feel as
though he did not understand the urgency of my need. I stopped my role playing and admonished him
to stop being so damn professional! He
had to show emotions and allow himself to be more human to me as the angry
person in order to build my trust and allow for positive influence. At the same time he could not reflect my
anger to the point of inflaming an already difficult situation. He had to understand, acknowledge and direct
both his and my (in my actor role) emotions in such a way as to create better
paths towards high value solutions. These
same observations hold true for discussions within organizations as well as
discussions with patients and other stakeholders. <o:p></o:p></div>
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The issue of how we reconcile the differences in emotional communication
between clinical health professionals and managerial health professionals in
order to develop systems that are optimal for patients is critical. We must, when designing health delivery and
care management systems, build them in ways that encourage the understanding of
emotions in order to foster better decision making by all involved. Unless the people on both the clinical and
managerial sides of health care can come together and communicate well, the
chance of developing better ways to build structures and processes that encourage doctors,
nurses, patients and families to work together for maximum effectiveness and
efficiency is significantly hampered. <o:p></o:p></div>
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In health care especially, the decisions that doctors, patients
and families must make when someone is sick are perhaps more fraught with
emotions than almost any other decisions.
Our management systems must reflect, acknowledge, and proactively address
this reality. These realities must be
understood and used in the same way that objective data, both quantitative and
qualitative is understood and used. Failure
to do so, whether in care management decisions or business decisions will
result in poor results for the patient and the organization. <o:p></o:p></div>
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<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">At Accolade, we take an approach which involves
acknowledging the emotions, understanding them and then either attempting to
encourage them, minimize their impact, or direct them in a more useful
way. Internally, as a company combining
smart people from the clinical and business worlds, we constantly work to
understand the different emotional communication styles that all of our
dedicated professionals bring to the table.
In the same vein, for care delivery systems, equal focus on the
providers’ emotions while working with patients is also critical. As Winter says, “our emotions are more
rational than we think” and in health care, we must bring the same rigor to
their evaluation, study and to the impact they make on medical decisions as we
do for staging and treatment of cancers and other diseases. We are human.
Emotions are part of the human condition. Let’s stop making believe they are not
important or not relevant to care and to good management and address them
constructively.</span>Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-65387703889403423332016-01-25T05:08:00.002-08:002016-01-25T16:58:48.992-08:00The Cost of Care When Nothing is Wrong<div style="margin-bottom: 10.0pt; margin-left: 0in; margin-right: 0in; margin-top: 0in;">
<span style="font-family: "calibri" , sans-serif; font-size: 11pt;">For many years, healthcare management has focused on the small
percentage of people who drive very high costs. I admit that I have
never been comfortable with that formulation. I could never get past the
reality that people who are spending the most money in health care are really
sick. They are having surgeries and being hospitalized – taking very
expensive biological agents and chemotherapy, and have diseases such as cancer
and sepsis, strokes and myocardial infarctions. They are the exact people
who should have the most money spent on them. While focusing only on that
small percentage of people who are the sickest is perhaps administratively less
costly and helpful to those individuals, as it gives those people the
coordination they require which does save some money, it targets those with the
lowest percentage of unnecessary care.</span>
It ignores the much larger number of patients, with the larger percentage
of unnecessary care, representing the bulk of those who seek care.<o:p></o:p></div>
<div style="margin-bottom: 10.0pt; margin-left: 0in; margin-right: 0in; margin-top: 0in;">
<span style="white-space: pre-wrap;"><span style="font-family: "calibri" , sans-serif; font-size: 11pt;">In my years of professional practice in the field of gastroenterology, more than half of my patients had pain and symptoms with no disease that could be found by testing. They were people with belly pain, constipation, and diarrhea who were suffering, but had normal blood tests, normal x-rays and normal endoscopes. They often spent large amounts of health care dollars as they bounced around the medical system, getting repeat tests, going on more visits to different specialists,and trying to find ways to cure their ills. I was fairly successful treating those people because I understood, in the </span></span><a href="http://www.nejm.org/doi/full/10.1056/NEJM199303183281123"><span style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt;"><span style="white-space: pre-wrap;">words of Francis Peabody</span></span></a><span style="white-space: pre-wrap;"><span style="font-family: "calibri" , sans-serif; font-size: 11pt;"> spoken in 1925, that “The secret of the care of the patient is caring for the patient.” I would see these types of people, talk to them about the issues in their lives that were causing them distress, and often instruct them to drink more water (I became famous for my water cure.) Most importantly, I would tell them to come back and tell me how that worked because I was interested in how they felt. I asked them about their life and how their pain was affecting their work, family and finance. Being attuned to the life context of patients has now been shown in controlled studies to have tremendous impact on the quality and </span></span><a href="http://www.contextualizingcare.org/"><span style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt;"><span style="white-space: pre-wrap;">cost of care by Saul Weiner and Alan Schwartz</span></span></a><span style="white-space: pre-wrap;"><span style="font-family: "calibri" , sans-serif; font-size: 11pt;">. Only rarely did I end up referring them to psychiatrists or psychologists, as I knew that the minute they perceived that I was telling them that there was nothing physically wrong, that it was “all psychological,” was the minute I would lose their trust. I took these lessons with me as I entered the world of health policy and care management. </span></span><o:p></o:p></div>
<div style="margin-bottom: 10.0pt; margin-left: 0in; margin-right: 0in; margin-top: 0in;">
<span style="white-space: pre-wrap;"><span style="font-family: "calibri" , sans-serif; font-size: 11pt;">In my health policy career, I studied populations and reviewed data and learned that while these types of patients may have been over 50% of my practice, they were an even larger percentage of primary care practices. Much of primary care is actually the art of following Voltaire’s dictum that “the role of the physician is to entertain the patient while nature cures the disease.” That is to say: finding ways to help people for whom there are no answers by lab and imaging and whose problems will abate over time. From a population health point of view, these people do not fit neatly into the high cost cohorts that we try to target. Yet, these are people in pain and distress coming to the doctor to relieve that pain. Sometimes they are people with chronic diseases however often their immediate pain is not related to their battles to manage their diabetes or heart disease. They are in the health care system, spending money as a measure of hope, and a significant percentage of those dollars spent are unnecessary. That gets to the heart of the best way to save money in health care….focusing on the unnecessary care that is often directed towards those who are the most difficult to treat and manage, because their problems do not fit neatly into the boxes that we in medicine want to create. </span></span><o:p></o:p></div>
<div style="margin-bottom: 10.0pt; margin-left: 0in; margin-right: 0in; margin-top: 0in;">
<span style="white-space: pre-wrap;"><span style="font-family: "calibri" , sans-serif; font-size: 11pt;">A recent review in the Harvard Review of Psychiatry provocatively entitled, “</span></span><a href="http://journals.lww.com/hrpjournal/Abstract/2015/11000/Medically_Unexplained_Symptoms___Barriers_to.4.aspx"><span style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt;"><span style="white-space: pre-wrap;">Medically Unexplained Symptoms: Barriers to Effective Treatment When Nothing Is the Matter” By Lipsitt, Joseph, Meyer and Notman</span></span></a><span style="white-space: pre-wrap;"><span style="font-family: "calibri" , sans-serif; font-size: 11pt;"> discusses the problem and suggests principles around how best to treat such patients. It starts out by describing a composite model patient who has belly pain and is afraid of having ovarian cancer, as her aunt had recently died of ovarian cancer. The authors describe a cycle of having evaluation after evaluation with nothing found, and the physician referring her to psychiatric care. As they state, “She feels misunderstood, rejected, disappointed, and angry. She decides to find another doctor. The cycle repeats for several months.” They point out in the article, “These patients pose a significant burden to practicing physicians and the health care system, with estimates of nine times the cost of general medical care per patient.” </span></span><o:p></o:p></div>
<div style="margin-bottom: 10.0pt; margin-left: 0in; margin-right: 0in; margin-top: 0in;">
<span style="white-space: pre-wrap;"><span style="font-family: "calibri" , sans-serif; font-size: 11pt;">The article suggests that the way to treat these people is to make the relationship paramount, and to focus on care versus cure. This approach creates a clear path for health policy and care management in which the ability to build trust with these types of people is critical to accomplishing lower costs and higher quality for the population, as these are the patients who make up the majority of all physician visits, and have the highest percentage of unnecessary care . It is not as low cost administratively as focusing on small numbers of expensive patients; however it is a more effective way towards effective cost reduction and quality
improvement. </span></span><o:p></o:p></div>
<br />
<div style="margin-bottom: 10.0pt; margin-left: 0in; margin-right: 0in; margin-top: 0in;">
<span style="white-space: pre-wrap;"><span style="font-family: "calibri" , sans-serif; font-size: 11pt;">The model of care management we have built at Accolade allows these people to build a trusting relationship with Health Assistants who care for them as people while we allow the physicians and nurses who are evaluating and treating them to find the cures. The small number of people who become high cost patients are parenthetically better managed because they have formed trust with an assistant before the coordination they require is necessary. It is an approach that assumes physicians practicing good medicine and assumes rational but emotional patients who need a trusted, caring person to be on the healthcare journey with them. It follows Peabody’s dictum while achieving lower costs, as it is about caring rather than curing, regardless of the disease label, or lack of a disease label. While such an approach may modestly increase administrative costs, it dramatically lowers total costs by addressing unnecessary care. Simply put, relationships are cheaper than tests and hospitalizations, and eliminating unnecessary costs by cultivating purposeful relationships will bring us closer to our health care goals. </span></span><o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-17349436196257772852016-01-11T12:42:00.000-08:002016-01-11T12:42:10.954-08:00Physicians on the Assembly Line<div class="MsoNormal">
The role of the physician in our evolving medical system is
the subject of many studies, articles and angst on the part of the physician
community. <a href="http://www.nytimes.com/2016/01/10/business/doctors-unionize-to-resist-the-medical-machine.html?_r=0">In
an article this week in the New York Times</a>, about the efforts by a group of
physicians in Oregon to unionize, the physicians involved discuss how their
creative assessment and problem solving skills are brought to bear in even the
most mundane cases. Dr. Rajeev Alexander,
one of the physicians involved is quoted as saying, “Real life is all about the
narrative. It’s sitting down and talking
about bowel movements with a 79 year old woman for 45 minutes. It’s not that interesting but that’s where it
happens.” Dr. Alexander may start out
believing the source of this elderly woman’s constipation is related to
dehydration, often the most common cause when elderly people have to be brought
to the hospital due to bowel problems, however he is following the best medical
approach by spending time to first determine that the problem is not something
less common, and then trying to also determine factors that may contribute to
the dehydration. He brings a cognitive
approach rather than a strictly reflexive approach. However his approach from a pure resource
management point of view may not be seen as efficient, hence the disagreements
that led to the physician group forming a union. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The system clearly needs to be more efficient. We must be both customized and thoughtful for
each patient, and also recognize that much of medicine is the same from patient
to patient. We must build more
efficiency into the system. Is the best
way to do this by taking the traditional leadership role of physicians in
patient care and making them into unionized workers? In that same article, Dr. Brittany Ellison,
another member of the physician group says, “We’re trained to be leaders but
they treat us like assembly line workers.
You need that time with the patient where his wife is ratting on him.” Is the best way to accomplish this by making
the role of the physician be more of a follower – of algorithms, of management
incentives, and of organizational goals, than a leader for their individual patient? Should they be judged on population effect,
efficiency and data capture rather than their work of caring for the
individual? <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
While I have an MBA from Northwestern University and
twenty-five years of experience working on the business side of the health care
industry, I do not believe the answer lies in money, bonus programs or
physician incentives. I have found, that
while physicians are people and want to make money and earn incentives, they
are driven more by their own sense of commitment to their patients and their
own sense of professionalism. Dr. Robert
Wachter, chief of the division of family medicine at the University of
California, San Francisco in that same article states, “If at the end of the
year, 10 percent of your salary is at risk based on whether you have
consistently clean hands, what patients say about you, readmission rates, that
can be OK. The counterargument is that you could screw things up by tying
everything to financial incentives. You
stomp on their intrinsic motivation.” <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Appealing to that intrinsic motivation is critical for the
individual patient interactions that make up that data. The goal when I or the professionals who work
with me at Accolade, help people through the health care system is to find ways
to bring out the best in people by finding ways to use the internal motivation
of both doctor and patient. We help
people find the right clinicians for the problems they have and help them
communicate with their doctors, nurses, and other health professionals in such
a way so as to bring out the best in their clinician. <o:p></o:p></div>
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<br /></div>
<br />
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Maybe we have to rethink the role of the doctor. Perhaps we need to reserve the use of the
doctor as a true leader and always team them with another professional who can
spend more time filling in the blanks for them.
We have experiments going on around the country which are as varied as
having nurse practitioners be the front lines for most patient interactions, to
having scribes be with doctors to free them from the data capture duties that
they have. At Accolade we have pioneered
a new profession of Health Assistant to assist patient and doctor with the life
context issues, emotions and clinical decisions that patients must make (which
specialty to see for my problem, what questions should I ask the doctor, how
can I balance my life responsibilities with my compliance needs). A Health Assistant who is part of a team led
by a creative problem-solving physician could make the physician more efficient
and allow for more access to the system.
Whatever the solutions that are
developed, it should not be to make the physician into an assembly line
worker. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-52801423832683117752016-01-03T10:14:00.001-08:002016-01-03T10:16:32.329-08:00“Strangers at the Bedside” and the Internet Economy<div class="MsoNormal">
In my last post, I wrote about information systems and
health care and the challenge of finding and treating the “black swans” which often
separates superior medical care from barely
adequate or even bad medical care. I
define barely adequate care as care that inadvertently takes advantage of the body’s
tendency to heal itself and represents a doctor and /or nurse being more lucky
than smart. The movement from medicine
being an art, a science and a profession to also being a business is today tied
to an economy which is rapidly changing as the Internet economy becomes a major
factor in our lives and therefore in health care. <o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
But first, I must pursue some personal history. In my education and development both as a
physician and as a healthcare systems expert, certain books were formative,
having a dramatic impact on my thinking.
One such book was “<a href="http://www.amazon.com/Strangers-Bedside-Bioethics-Transformed-Institutions/dp/0202307255">Strangers
at the Bedside</a>” by David J. Rothman.
Professor Rothman is a historian by training however he holds the post
of the Bernard Schoenberg Professor of Social Medicine and Director of the
Center for the Study of Society and Medicine at Columbia University. To make this personal story more complex,
Bernard Schoenberg for whom Professor Rothman’s academic post is named, was a
professor of mine at Columbia when I was in medical school and was someone who
taught me to look at the social and emotional context that each patient brought
with them to the doctor-patient encounter.
<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
In his book, David Rothman describes the changing dynamic in
social and ethical issues in medicine, especially in those issues involving
clinical research, end-of-life, and other bioethical dilemmas such as choosing
patients for transplants with limited access to donor organs. He discusses the arrival of sociologists,
ethicists, theologians and others trained in the humanities into these
decisions that previously were the purview of only the treating physician. In a future post I plan to write more about
David Rothman’s words now twenty-five years after he wrote them. He does not write about the business people,
the management experts and the information technology engineers and their entry
into the bedside dynamic yet those may be the more important “strangers at the
bedside” in today’s world.<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
As medicine, health care delivery systems, and health information
technology progress, the industry must be informed by more than medical facts
and prospective. Thomas Friedman’s 1999
book entitled “<a href="http://www.amazon.com/Lexus-Olive-Tree-Understanding-Globalization/dp/1250013747">The
Lexus and the Olive Tree</a>” in which he describes the drivers behind
globalization has nothing to do with health care. In that book, which came only eight years
after David Rothman’s book, Friedman talks of a changing world and speaks about
the democratization effect that globalization could have on technology, finance
and information. I remember reading his
book when it was first published and believing, somewhat naively perhaps, that
he had left out the democratization of health care in his formulation. I believed that through the internet and
through the free movement of health and medical information, health care which
is far too important to be left only to doctors, as David Rothman points out so
elegantly, was going to undergo a revolution for the better by making the
mystery of medicine – the guild aspect of the medical profession – fall to the
wayside of an informed, democratized public.
<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
I was too optimistic.
I minimized the profound complexity of medical care and the fact that
people, for the most part, access medical care only episodically and focus on their
life issues before focusing on their health issues. I left out the spiritual dimension of care
that is a necessary part of medicine and has been written about so eloquently
by people such as Daniel Sulmasy, who wrote another of my formative books, “<a href="http://www.amazon.com/The-Healers-Calling-Spirituality-Professionals/dp/0809137291">The
Healer’s Calling</a>.” <o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
I also missed the nature of an Internet economy and the tendency
towards monopoly that often defines the best Internet companies. A recent article in The New Yorker by Om
Malik entitled, “<a href="http://www.newyorker.com/tech/elements/in-silicon-valley-now-its-almost-always-winner-takes-all">In
Silicon Valley Now, It’s Almost Always Winner Takes All</a>” cogently presented
the reasons for this monopolistic tendency to prevail in this “democratized”
world. As Malik writes, “In the course
of nearly two decades closely following (and writing about) Silicon Valley, I
have seen products and markets go through three distinct phases. The first is when there is a new idea,
product, service, or technology dreamed up by a clever person or group of
people. For a brief while, that idea
becomes popular, which leads to the emergence of dozens of imitators, funded in
part by the venture community. Most of
those companies die. When the dust
settles, there are one or two or three players left standing. Rarely do you end up with true competition.” <o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Malik writes about the Network effect, often called Metcalfe’s
Law after Bob Metcalfe inventor of The Ethernet, which occurs when the value of
a product or service goes up with the number of people using it. It creates a loop of algorithms,
infrastructure, money and data and that leads to a winner-take-all approach. This is especially recognized by the
investors who provide the capital for these new companies. The investor community and the public markets
take large risks to predict the next monopolies and in this Internet economy,
punish anything less than a monopoly or a duopoly since according to Malik’s
cogent analysis, most of those companies die.
<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
What happens when this winner-take-all type of economy meets
health care? In some ways we have a
direct example with Epic Systems which now supplies the hospital software that
holds 54% of the US population’s health records. It is a marvelous system designed by
engineers and hospital administrators and is masterful at capturing data for
billing purposes and for inventory purposes.
Physicians will tell you it can divert their focus from the patients and
while it does make accessing records when not at the bedside easier, it does
not tell the patient’s story – their life context and emotional struggles with
illness that are critical to good care, in the way it must. Competition is being shut out because, as
Metcalfe’s Law suggests, the more EPIC is the standard and the more data they
have, the more monopolistic they can become.
There is an old joke told in the early days of computing (and I am old
enough to remember). It goes, “How many
Microsoft engineers does it take to change a light bulb?” The answer – “None because Bill Gates
declared that darkness is the standard.”
Will we define a health care standard that removes the human aspects from
care even though those elements are arguably the most important?<o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
Perhaps a good example that is not in health care and not
even in the Internet is the story of agribusiness in the United States. In the food business, four companies control
over 60% of grain production. This came
about from a starting point of an America whose food came almost entirely from family farms. It occurred because the Internet realities of
algorithms, infrastructure, money and data have their counterpoints in food production,
in land, infrastructure, money and logistics. The more you control land, infrastructure and logistics, the more money you can raise and the more you can increase control of the market. On the positive side, this has led to more efficient use of farmland,
more availability of food to the market on a year round basis, and more
consistency in preventing food borne illness.
On the negative side, we have been subject to monopolistic tendencies by
these companies, leading to episodic need for lawsuits and regulatory action, a
loss of family farms and the communities they supported, and a loss of the
unique aspects of local food that can lead to healthier more varied diets. We have traded efficiency and the positive of
availability for a loss of flavor (for those of us who value that), loss of varied
nutritional sources, and perhaps potential environmental damage as well (I will
let those discussions occur elsewhere).
Management and finance prioritized over dedication and even love of the land
and the amazing variety of food the land produces have driven this
tendency. <o:p></o:p><br />
<br /></div>
<div class="MsoNormal">
I now watch the froth of Internet health companies being
pursued and funded by venture capitalists and the hope being put into
information technology in health care by both government and investors. I welcome the creativity and the new
approaches but wish those to be driven by a desire to improve the care for each
unique patient as well as the desire to foster efficiency. I for one remain enamored of a democratization
of health care and repeat a line I wrote earlier in this post and have been
saying for years, that health care is too important to be left to doctors and
nurses. However, health care is also too
important to leave out doctors and nurses.
It is too important to leave health care only to the management experts
and the information system engineers.
Health professionals train and take oaths and have experience that gives
them a special voice in protecting the personal aspects of medical care. <o:p></o:p></div>
<br />
<div class="MsoNormal">
David Rothman states that while “the physicians are alert to
numbers and findings from random clinical trials carry critical authority” they
also recognize that no two patients are alike and that medicine is inherently
uncertain. Clinicians value experience highly
as they realize that only through experience do professionals understand the
management of that inherent uncertainty and how individuals can vary from the
clinical trials. Experienced clinicians understand, as I
discussed in my last blog, the importance of always looking for the unexpected. We as patients – and we are all patients at
one point or another – should also value that knowledge and experience and
always hope to have doctors and nurses, who use technology and who respect our
ability to find information for ourselves on the Internet and from other
sources. We should also demand that the
technology support health professionals treating us all as the potential “black
swan” – the unexpected disease or circumstance and not as a data point in an
Internet algorithm or on a balance sheet.
I believe that can only occur if experienced caring clinicians are
involved in the development of this new world of the health care Internet
economy and ironically do not end up as the new strangers at the bedside.<o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-89572107093734394462015-11-30T06:18:00.002-08:002015-11-30T06:18:27.370-08:00Information Systems, Good Medicine and the Search for Black Swans<div class="MsoNormal">
Many years ago, when I was in medical school, learning the
art of the physical exam, I was taught that the exam should always be done in
the same order each time, starting with the skin, moving to the head and then
working your way down, leaving the rectal exam and the exam of the genitalia
for last (more for the comfort and the dignity of the patient). It was drilled into me that it must always be
done from the right side of the bed or exam table. That consistency and discipline in performing
the physical exam the same way each time was considered a critical element of
good medicine. <o:p></o:p></div>
<div class="MsoNormal">
While the idea of a physical exam in general may be seen
quaint and outdated in our era of telemedicine, scans, apps that can monitor
bodily functions and other imaging technology, the discipline of the physical exam
and even the emotional impact of that exam is hardly outdated. Abraham Verghese, the esteemed author, physician
and educator has written and spoken about the importance of the physical exam
in both a <a href="https://www.ted.com/talks/abraham_verghese_a_doctor_s_touch?language=en">ted
med talk</a> and <a href="http://www.bmj.com/content/339/bmj.b5448">in the medical
literature</a> and his words are worth reviewing. Verghese emphasizes the ritual part of the physical
exam, and the importance it holds in bonding the physician and the patient. He writes, <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
“…….the ritual of the bedside
examination involves two people meeting in a special place (the hospital or
clinic) wearing ritualized garments (patient gowns and white coats for the
doctors) and with ritualized instruments, and most importantly, the patient
undresses and allows the doctor to touch them.
Disrobing and touching in any other context would be assault, but not
part of this ritual which dates back to antiquity.”</div>
<div class="MsoNormal" style="margin-left: .5in;">
<o:p></o:p></div>
<div class="MsoNormal">
He goes on to say,<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
“We propose that if the ritual is
short changed, if it is done in a cursory fashion, if it is not done with skill
and consideration, if its sacredness seems to be violated, then the
transformation (which in this case is the formation of the doctor-patient bond,
the beginning of a therapeutic partnership and the healing process) does not
take place.” <o:p></o:p></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
His words reflect the way a good physical exam helps form
the basis for the doctor-patient relationship.
However that is not what I will choose to dwell on in this post. Rather I want to discuss the ritual
itself. The very rote and disciplined
way the examination is done each and every time a physician, especially an
internist or family physician sees a patient.
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Back in medical school, I was taught to perform the exam very
precisely each time for a simple reason.
I was told that if I did the exam the same way each time, it would make
it more likely for me to notice anomalies.
I would notice something that was not like the thousands of other exams
I had done. In many ways, medicine is
extremely repetitive. Because of this
repetitive nature of practice, it is very easy for physicians (and nurse practitioners)
to go on auto pilot – to become reflexive in their actions instead of remaining
cognitive with every patient and through every exam. At the same time, high quality medicine is
all about finding the needle in the haystack: noticing the unusual exam finding
that might suggest an illness that could turn into tragedy. In order to find that “black swan” (defined
as an unpredictable or unforeseen event or diagnosis, typically with extreme
consequences) one must sift through thousands of exams that are very usual and
very common. One must feel a lot of
normal livers and listen to many normal hearts to find the one that is
indicative of a disease. It is so easy
not to notice! It is so easy to take
shortcuts and not go through the discipline of the exam. <o:p></o:p></div>
<div class="MsoNormal">
The result can be a missed diagnosis and ironically a more
expensive evaluation, as unfocused diagnostic evaluation often called shotgun
medicine, requires numerous tests which are unnecessary if instead the exam is
thorough. An example is the 50 year old patient
who comes in with chest pain. On the
basis of that history and a lax approach to the physical exam a cardiac evaluation
would be done which could include stress tests, and even cardiac
catheterization. If one however does a physical exam and notes
that the pain is in one dermatome (an area of the skin supplied by nerves from
one spinal root) and that small vesicles can be seen, the diagnosis of shingles
is made and no further evaluation is needed.
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I sat once on an airplane next to a psychologist. He told me that he had been an airline pilot and
had developed a psychological test to see if prospective pilots would be good
in the cockpit. He left the pilot’s seat to develop this test as he felt his
ability to improve airline safety would be greater in promoting widespread use
of the test than in his flying planes. The
key to being a good pilot was to be highly intelligent but not too
intellectual. You had to do the same
things every time you took off and landed.
On each take-off, you had to make a decision as to whether to abort the
take off and it had to be a conscious decision.
You could not allow your mind to wander (in his definition an
intellectual is one whose mind does wander) or have the take-off become so
reflexive that you don’t notice small differences from the normal take-off. It seemed to me that the similarities to
medicine, especially primary care medicine, were apparent and so it also seemed
to Dr. Atul Gawande.</div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
Atul Gawande noticed the use of checklists in the cockpit of
an airplane and it led to his writing “<a href="http://atulgawande.com/book/the-checklist-manifesto/">The Checklist
Manifesto</a>” which advocated for checklists in medicine, similar to the
checklists in aeronautics. In a real
sense, Dr. Gawande was only harkening back to the medical school truism of
finding ways to do repetitive tasks, such as the physical exam, in such a way
that that steps in the processes were not missed and abnormalities were more easily noticed. Checklists are a way to highlight deviations
from the norm and to ensure that we do everything in medicine in a disciplined
way.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
However, as we started to computerize our routines, and
started to monitor them using modern information technology including EHRs and
other electronic tools, we may have lost our way a bit. The goal of routine leading to more easily
noticing deviations from the norm took second place to pure efficiency and
blind adherence to protocol. The idea of
the best doctors being those who were complete even compulsive and who found
the black swans was replaced by the idea that the best doctor was the one who
could prove adherence by having all the computer fields filled and prove
efficiency by doing so most quickly. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Computers allow us to copy and paste and pre-populate fields
for the sake of efficiency. If we do the
same exam each time and nine times out of ten the exam is normal, doesn’t it
make sense to just prepopulate the normal exam and doctors can then change the
results as needed? However having the
areas prepopulated does collide with one of the secrets of medicine, namely
that doctors are people and they work towards incentives and towards the path
of least resistance as other people do.
When you have a computer record field that is prepopulated, and you don’t
think something will be abnormal, and you have a waiting room full of patients,
you tend, as a person, to just accept the prepopulated answer and skip the
actual exam component. By doing so, your
organization (and more and more physicians are employees of larger
organizations) will receive higher reimbursement for a more intensive exam
because it is documented that more was done on the exam. The physician will get a higher report card
grade, leading to a better bonus because they did more complete exams or so the
computer says. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
By the same logic, in the hospital setting, in which multiple
physicians and nurses all having different roles and responsibilities may see a
single patient, the ability to copy and paste someone else’s exam since it is
likely to be the same as yours, is not seen as dishonesty or poor medicine,
only as a way to be more efficient and more productive. The
fact that it removes an internal quality check and that each health
professional may notice something missed by another is not factored into the
development of the system. If someone is
sick enough to require hospital level care it only makes sense to have multiple
checks in place to guard against mistakes that could cost someone their
life. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As an example: for one patient, the head, eyes, ears, nose
and throat exam (HEENT) was presumably done because it was pre-populated. In
reality the physician skipped actually preforming that part of the exam. The
patient being seen had known Irritable Bowel Syndrome and came in with
constipation and abdominal pain that was not very different from when seen
during the previous visit. The rationale
was that the HEENT exam was bound to the unchanged from the previous visit. But this time could have been different and
the good doctor, would have either changed the pre-populated fields to reflect the
head was not examined, jeopardizing his or her own job evaluation by the health
care organization, or actually done the potentially unnecessary part of the exam,
lengthening the appointment in such a way as to either not have time to focus
on the problem at hand or run late in the clinic and hurt his or her service
evaluation, also harming the job evaluation.
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
This is not a problem with the information technology. These tools can help us achieve and monitor the
exam routines I learned more than 40 years ago.
What is missing is the proper
design of these systems to support those noble goals of finding the black swans
and focusing further testing and therapeutics, rather than the simpler goals of
efficiency and adherence to a norm. Missing
from our currently designed systems are the aspects of human engineering that
understand how patients, physicians, nurses and therapists really work and
think. We cannot afford to ignore the need
for constant diligence to find something unexpected – something unusual that
will make the health professional stop and think and perhaps save someone’s
life. It is not an impossible
challenge. It can be done and must be
done for the promise of information technology in medicine to truly be
met. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-15243330730101323922015-11-22T06:55:00.000-08:002015-11-22T06:55:31.128-08:00Technology, the Triple Aim, and the Three Laws of Robotics<div class="MsoNormal">
<a href="http://content.healthaffairs.org/content/27/3/759.full">The triple aim of
health care</a> (improve the patient experience, improve population health and
lower per capita cost) remains the driving force in health policy since Donald
Berwick, Thomas Nolan and John Whittington first described it in Health Affairs
in 2008. Information technology is now
being used in ways unimagined in the past to drive the triple aim, often with less
success than had been anticipated. The
challenge has been and continues to be, using information technology effectively
while maintaining the aspects of medical care that require the human touch. The real challenge is how to harness the power
of the computer in what must remain a caring pursuit. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It is clear that our quest to incorporate computers into
medical care and perhaps even direct medical care, risks losing the essence of
medicine – the humanism and caring tradition that should be paramount. I have written before in an earlier post of
my own experience in the hospital and the fact that I felt ignored as the staff
worked diligently to address the need to answer the computer’s demands (<a href="http://www.healthwealthandlife.blogspot.com/2015/06/my-recent-hospital-stay-and-care-of.html">My
Recent Hospital Stay and the Care of the Computer</a>). Yet I
know that our ability to properly use information technologies will help
improve medical care. The real question is,
and will be, will the health care system effectively use technology to improve
care and foster the humanism inherent in care or will the technology itself
define a new system which is driven only off the zeal for efficiency and the best
science of disease, but which leaves the hands-on humanistic and spiritual
tradition of medicine in the dustbin of history. <o:p></o:p></div>
<div class="MsoNormal">
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When I was in college, in the late 1960s, early 1970s, I had
a friend who was getting a degree in the early field of computer engineering
and programming. He was a strange sort
of guy who used to rail about the evils of computers. He would talk about how they were actually imbued
with malign intentions and evil spirits.
When asked why then he wanted to go into computer science, he would
answer that someone had to control them in order to defeat the evil that was
inherent in them. In today’s world, and especially
in today’s world of computers in medicine, I wonder if he wasn’t on to
something. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Certainly in popular culture the ideas of computers having
an evil dimension and even dominating humans is examined both by those at the
cutting edge of science and by those in the arts. Physicist Steven Hawking has been one of the
more vocal scientists who have warned of the risk that computers, via the use
of artificial intelligence, could, “spell the end of the human race.” Bill Gates and Elon Musk have also voiced
their concerns in calling for more research on the potential for computers to learn
to “think” for themselves and evolve themselves and where this could
potentially lead including the possibility of information technology
controlling human action. As recently as
June of this year, Steve Wozniak, co-founder of Apple, created media buzz by
declaring that in the future, humans will be the pets of computers. Science
fiction has explored this concept for many years, with Isaac Asimov inventing
the “<a href="http://io9.com/why-asimovs-three-laws-of-robotics-cant-protect-us-1553665410">Three
Laws of Robotics</a>” which aimed to protect mankind from the control of machines. He then proceeded to build stories to show
the inadequacy of the three laws in protecting humans and humanity. As
written by Asimov the three laws are:<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: .5in;">
“A robot may not injure a human
being, or, through inaction, allow a human being to come to harm. A robot must obey orders given it by human
beings except where such orders would conflict with the First Law. A robot must protect its own existence as
long as such protection does not conflict with the First or Second Law. <o:p></o:p></div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal">
The laws all stress the need to help men and women however Asimov’s
stories show the reality of unintended consequences when good intentions can
cause bad even evil results. The reality
is that when human arrogance believes that control can be total over the world
around us (including the technology we create) the results often can prove us
wrong in painful ways. In medical care,
this may prove to be especially dangerous as the results are highly personal
and could be life-threatening. Medicine
is filled with low probability, high consequence events and information
technology is invariably designed for populations, rather than the black swans –
the unpredictable, rare but high impact event that can radically affect a
person’s life. Our systems approaches to
date have also not taken into account the values, beliefs and social structures
that we all live under. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
While the three laws of robotics do not directly address the
same issues as the triple aim, the idea that certain hard wired goals, or laws
can address all eventualities, and all permutations, is similar. Both the triple aim and the three laws of robotics
are inherently good: however any laws developed by man that are ultimately
taken as holy writ and hard wired into computer systems, can be interpreted in
such a way as to create pain for individuals.
In medicine, one of the dangers of technology being programmed to
address certain components of the triple aim is that while service and quality
are implied in the first aim, it is not stated clearly who defines either
service or quality. More and more we
have studies that show that the “system” definitions as determined by those who
design and run the health care organizations are different than physician and
nurse definitions which are different than patient definitions. A certain decision algorithm, being driven by
information technology, may not support the goals of population health and
lower per capita cost but, due to the unusual nature of the disease and of the
patient’s psychosocial situation, may help that person in need. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
David Shaywitz, one of the best thinkers in health care and
a blogger for Forbes, recently wrote a short blog entitled, “<a href="http://www.forbes.com/sites/davidshaywitz/2015/10/31/first-we-devalued-doctors-now-technology-struggles-to-replace-them/">First,
We Devalued Doctors; Now, Technology Struggles to Replace Them</a>” in which he
describes the challenge of trying to
have technology drive personalized medicine which depends so much on knowing
the psychosocial dynamics of each person being treated. He writes, “I realized there was something
that seemed a little sad about the idea of developing extensive market
analytics and fancy digital engagement tools to simulate what the best doctors
have done for years – deeply know their patients and suggest treatments
informed by this understanding.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
I agree. It is sad that
society may be abdicating the sacred trust of knowing the person to a computer rather
than to a caring professional. But it is
not too late to change the new paradigm being written. We can
effectively find a way to control the computer and use the capabilities
inherent in that technology to augment the humanism of the professional helping
those who are in need. We can prevent a
purely technological approach to the triple aim going the way of the three laws
of robotics in literature and being the fodder for tragic stories of individual
pain. It will take new information technology and new approaches that are carefully designed to foster humanism, as defined by the patient and
the family. Caring can be improved if we
learn how to use information technology in a way that supports and helps our
professionals focus more on understanding each patient as a unique individual
and not just a set of pathologies. My strange friend from forty years ago had
confidence that he could fight the inherent evil of computers and I too am confident
that we take harness the power of technology to improve the professionals’
ability to care for patients.<o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-30676354081771487222015-11-09T04:12:00.000-08:002015-11-09T04:12:01.705-08:00Apps, Attention, and Obesity<div class="MsoNormal">
At one point in my career, since I have a strong background
in nutrition (I am a Fellow of the American College of Nutrition and was board
certified in clinical nutrition) I thought I would make my fortune by writing
the ultimate diet book. It was really
very simple. On each page I would print
the following message:<o:p></o:p></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: 14.0pt; line-height: 115%;">EAT LESS AND EXERCISE MORE<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: 14.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
Of course that was many years ago and now the current
version of my book is achieved by creating the ultimate weight loss app. The many apps that have appeared are as
equally effective as my book concept would have been. Or so it seems in a very nice <a href="http://onlinelibrary.wiley.com/doi/10.1002/oby.21226/abstract">study this
month in the journal Obesity</a>. The
Duke team, one of the best in the country in treating obesity, investigated whether
apps on a cell phone helped young obese adults lose weight. The answer was no. In their words, “this behavioral intervention
did not lead to significant weight loss relative to control at any trial time
point.” <o:p></o:p></div>
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<br /></div>
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In some ways, this is not surprising. Shlomo Benartzi, author of the book, <a href="http://www.amazon.com/The-Smarter-Screen-Surprising-Influence/dp/1591847869">“The
Smarter Screen”</a> and a professor and co-chair of the Behavioral Decision-Making
Group at UCLA’s Anderson School of Management, makes the point that computer
screens, or cell phone screens are “changing the way we think making us more
impulsive and reactive.” For behavior
change to occur especially when it comes to overeating, becoming <i>more </i>impulsive is not likely to drive a
successful strategy. He notes, that “people
think faster on screens, and this can lead us to become more reliant on our instinctive
responses and initial impressions, even when they are misleading and incorrect.” So while the app may tell you that you are
eating too much, it is unlikely to drive behavior to make you eat less impulsively. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I can have multiple apps on my cellphone, to manage my diet,
my activity, my sleep, my heart rate, my medications, and my medical
records. Many of these apps are based on
the theory that people just need more information about what they are doing and
how they are doing it in order to change.
The most elegant apps (technologically) also send messages to your
doctor or to a nurse if you or your numbers are out of line. However the question is whether all these
fragmented sources of personal information actually help us to modify our
behaviors. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
This focus on making it simple to keep track and give us
feedback on our own activities appears on face value to have some benefit. We can potentially be able to keep records
and “share” the information with the doctor or a nurse who can then
intervene. However it also can create
information overload for both the person who owns the device and the health
professional expected to intervene on the basis of the information. Benartzi points out the experience from the
VA Health System which has wonderful alarms within its medical records which doctors
routinely ignore because there are too many alarms and too little time and
attention. It turns out that too much
information – too many alarms – leads to a “scarcity of attention” – a term used
by Benartzi – and that scarcity is amplified in our screen based world.<o:p></o:p></div>
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Benartzi compares our new use of apps and computer screens to
Adam Smith’s treatise “The Wealth of Nations” written in the early stages of the
Industrial Revolution. He writes, “While Smith associated scarcity
with a lack of material resources – during the Industrial Revolution, people
needed more coal and wood and land – the most important scarcities of the
information age are psychological, and caused by our new abundance of
information. “ <o:p></o:p></div>
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<br /></div>
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When I was a health consultant, advising the Fortune 100 companies
on the health programs they put in place for their employees, I would often
point out that they were spending huge sums of money on multiple health
programs which ranged from weight loss, to stress management to disease
management to pharmacy management, each with their own separate information and
interventions for their employees and the employee’s families. I would then tell them that the only thing
that they were actually achieving was confusing the hell out of the same people
they were trying to influence and whose behavior they were trying to change. While at that time I admittedly did not know
all the decision science behind my consulting point, it turns out that what was
obvious to me has now been proved experimentally in numerous studies. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In the world of apps, it is hard to have a full picture of
the person trying to make the behavior change.
Life circumstances may make good diet and exercise virtually impossible
due to competing priorities, financial and time constraints, and emotional
factors. It is virtually impossible for
an app alone to address these points that are unique to each individual and
that are often constantly changing. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
In the article on cell phone weight loss apps, the Duke team
makes the point that behavioral change principles are often absent in the app
based commercial obesity products. Current
obesity treatment guidelines recognize the need to evaluate optimal frequency
and duration of contact on an individual basis which is hard to design into a
pure app solution. They conclude that
you need a combined approach that may require “the scalability of mobile technology,
the social support of personal coaching, adaptive intervention design and more
personally tailored approaches.”<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Apps and technology do have a role. However their role is in making already
effective programs and approaches scalable, easy and consistent. They are facilitators of solutions rather
than independent solutions. Part of our
challenge, is how to use these powerful tools, in conjunction with people and
other support and operational processes to truly help people to lose weight,
control their blood pressure, take their medications and maybe even just enjoy
their lives more. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
The apps alone, in providing information, will be hard
pressed to address the psychological and life factors that require the personally
tailored approaches the Duke authors in the article speak about. In many ways, our challenge for the foreseeable
future is how to harness the power of technology in the search for the more individualized
approaches that address people’s health, their life situations, their psyche,
and even their spirit in the quest to improve their lives. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-53652240614723143722015-10-25T07:56:00.000-07:002015-10-25T07:56:11.345-07:00What Patients Value in Everyday Medical Decisions<div class="MsoNormal">
Mary comes in to see her physician, who she has known for
five years, clearly worried. The trust between
them is excellent. Mary is 42 years old,
works as a waitress and has struggled with Metabolic Syndrome. It is hard to manage the high blood pressure,
high cholesterol and the need to maintain a healthy regimen of diet and
exercise when you are sometimes working two shifts, trying to manage two
teenage daughters and have a husband who is a truck driver and is gone much of
the time. The partnership between Dr.
Sheila Jones and Mary has been excellent through the years and that
relationship has led to control of Mary’s blood pressure and lipid levels even
while the ability to eat well and exercise is limited due to life getting in
the way. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Today’s visit is different.
Mary is frightened because two people she works with have been diagnosed
with breast cancer, and another third friend has also just started chemotherapy
for breast cancer diagnosed three months earlier. She knows that none of them are direct
relatives, and that she does not feel any lumps when she examines herself,
however she wants to be screened. Dr.
Jones sits and talks with her, telling her of the data that shows little to no benefit
to screening before age 45 or 50. Dr.
Jones knows that the <a href="http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs">American
Cancer Society guidelines</a> do say that women over 45 should be screened and
women ages 40 – 45 who wish to have a screening mammography should be able to
do so. However the <a href="http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening">US
Preventive Services Task Force (USPSTF)</a> says that screening should start at
age 50 and the healthplan follows those stricter guidelines. The screening mammogram may not be paid for
since Mary has no medical risk factors, only inordinate fear. Mary cannot afford to pay for a screening mammography
from her own pocket as money is very tight.
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Dr. Jones knows that, statistically, the test will offer no benefit. For Dr. Jones, ordering the screening
mammography will be a mark against her on the scorecard that the healthplan
keeps and may impact her income and even more importantly, her reputation as the
scorecard is available publically. Dr. Jones talks to Mary and tries to dissuade
her from having any test but Mary is not to be moved. She wants the test or will try to go
elsewhere to get it done even if that means switching doctors which she does
not want to do. Mary needs the
relationship with Dr. Jones to be strong as her Metabolic Syndrome successes to
date may be compromised by a breakdown in trust and a transition to a new
doctor. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Dr. Jones thinks
through her options. She can call the
healthplan medical director who may help her by making an exception however the
healthplan medical director is told very clearly that his job is to communicate
and obtain complex medical information that may not be reflected in the claims
data, and not to go against the medical policy of the plan. The healthplan lawyers are fearful that making
decisions against medical policy sets legal precedent and may be used as
evidence that they are not consistent in their fiduciary decision making. Trying to work through that system can be a
nightmare. Or Dr. Jones can order the
mammogram, not as a screening test but as a diagnostic test – a “rule-out”
breast cancer. She can say that she
feels something on physical exam even though she does not. It will maintain trust with Mary and will
allow Dr. Jones to continue to be seen as her advocate. It will also save time when she has twenty
patients to see that day. Dr. Jones
tells herself there is a small risk that a false positive will be seen on the
mammogram that will require more testing, perhaps even biopsy but there is also
an extremely small chance the mammography will show a true positive that was unsuspected! We are dealing with statistical probabilities
after all. Yes it involves telling a
small lie and having something paid for by the healthplan that should not be
paid for however how much more will it cost the plan if Mary’s Metabolic Syndrome
was totally out of control due to her losing Dr. Jones as a trusted physician and
she ended up with full blown diabetes, heart disease and all the
complications. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I present this as a dilemma and I admit for some, it is not
a dilemma at all. Many believe that the
doctor must base all their decisions on the medical guidelines, deny the test
and move on to the next patient. Dr. Barron Lerner, a professor of medical
ethics at NYU Medical Center recently wrote an <a href="https://www.washingtonpost.com/opinions/why-did-the-american-cancer-society-ignore-evidence-about-early-detection/2015/10/23/3368498a-78c7-11e5-a958-d889faf561dc_story.html">article
in the Washington Post</a> asking why the American Cancer Society took so long
to “ignore evidence about early detection” when they recently increased their the
screening age from 40 to 45 in breast cancer screening guidelines. He writes, “in
an era of cost containment, we need to prioritize payment for proven
interventions.” However we are also in an era of trying to
determine what the patient values not only what medical protocol says. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
In an article in <a href="http://jama.jamanetwork.com/article.aspx?articleid=2443231">JAMA Lynn,
McKethan and Jha</a> discuss the challenge that, as their title states it, “Value-Based
Payments Require Valuing What Matters to Patients.” They make the point that we must ask patients
what they value and then deliver on those priorities. However we must acknowledge that patients often
value reassurance and family concerns over the strictly medical. They are often more influenced by friends
and family than they are by statistics and expert opinions. In Mary’s case, she wants reassurance and
wants to know that her life balance will not be upended. She sees her friends struggling with all
aspects of their lives as they deal with this potentially deadly disease. They approach her about caring for their
children if they die. She must know that
is not about to happen to her and she wants that test. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In the JAMA article, the authors say “serious, life-altering
and ultimately life-ending chronic conditions, often in old-age, pose a
particular challenge for the health-care system because traditional
professional standards may not effectively address what an individual most
wants.” I take issue with that
emphasis. I believe that often the most
difficult issues are the more mundane, everyday issues that physicians and
nurses encounter in the outpatient setting in the course of their daily
practices. Just like the metaphorical flap of a butterfly
wing in Brazil (as described by Lorenz in chaos theory), that may change the course
of a tornado in Texas, these small interactions with patients everyday may have
in aggregate much greater effect than the issues of the patient dying of end
stage disease. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
The real challenge then is how to build these shades of grey
decisions into systems of care. These
decisions involve people’s lives and not only their diseases, and occur between
doctor, nurse, therapist and patient every day.
How can we make them work for both populations and for individuals? Ultimately we must build health care processes
and value based payments that respect the biomedical protocols as well as the
humanistic, emotional, social and financial concerns that drive people’s lives. We must build this for everyday medicine and
not just intensive care and end-of-life medicine in order to maintain people’s
trust in health care and solve our healthcare cost problems. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-47213433428297700742015-10-17T06:40:00.001-07:002015-10-17T06:40:42.099-07:00Is Bad Data Better Than No Data?<div class="MsoNormal">
We are now in the era of “big data” which, we are told, will
answer questions we could never answer and also identify individuals before
they are sick so we can intervene and prevent their illnesses and their
problems. It is exciting,
earth shattering and the subject of more articles, blog posts and conferences
than one can shake a stick at. However
is it true? Can “big data” or little
data for that matter really lead us to salvation (medically speaking at
least). <o:p></o:p></div>
<div class="MsoNormal">
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Forgive me for the religious association however it often
seems as though people are taking the pronouncements from the medical data
gurus as being holy writ from God. That
bothers me a bit because fundamentally being a monotheist I do tend to think
that we mere mortals are not godlike in our perfection, even if we are
physicians and even if we are the even godlier than physicians, health policy
experts. There is an old joke about a
good man dying and going to heaven. In
heaven he is shown around by one of the angels who take him to the dining hall
where a line of happy people are patiently waiting their turn to pick up their
food for the day. He then sees one of
the heavenly beings wearing a white coat with a stethoscope in a pocket cut
into line. He asks the angel who that is
and the angel says, “Oh that is just God – sometimes he thinks he is a
doctor.” Since we are not godlike in our
analyses, we must better understand what all this data means, and whether bad
data is better than no data. Ultimately
we need to know how to use data to help those in need. That is the essence of medicine – helping those
in need. <o:p></o:p></div>
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I speak as a physician and a health data expert who has helped
health care organizations, government and large corporations design programs
based on the populations they serve. The
work I do is data based and thus I must understand the strength and limitations
of data. I know that data can
potentially be used to positively impact the use of precious health care
resources and the care a patient receives.
At the same time, in my professional role, I am often the skeptic,
challenging those people who claim the data holds magical powers. Thus I enjoyed the article by Dr. Saurabh Jha
in the Health Care Blog entitled, “<a href="http://thehealthcareblog.com/blog/2015/10/11/quality-of-skepticism-and-skepticism-of-quality/">Quality
of Skepticism and Skepticism of Quality</a>.” It was his section on bad data
being better than no data that inspired this post. He makes the point, and I admit it is a point
I make all the time, that perfection is the enemy of good but does not stop
there as many do. Dr. Jha understands the limitations and that while perfection
is the enemy of good, sometimes data analytics do not even achieve the standard
of good. </div>
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What then is this data we are talking about? All data depends on some information, being
put into the right format to translate into the binary code that computers
understand. When people speak of big
data, at this point in time, they are mainly speaking of claims databases which
take billing codes from insurance claims and assume that they accurately
reflect the care that is being rendered.
Billing codes are financial tools that drive payment and are used by
providers to maximize their revenues (there are courses and consultants that
constantly try to help people adjust codes to do just that) and are used by
insurance companies to minimize payments.
That results in a game with only passing interest in accurately
reflecting what is going on between a doctor and a patient. With electronic medical records, the hope is
that we will obtain more accurate information on what is really happening. The funny part is that the most popular and
widespread EMR gained its market dominance by being able to help hospitals
maximize their revenues by capturing all services and materials for accounting
and billing purposes, not by accurately telling the clinical story.<o:p></o:p></div>
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<a href="http://www.contextualizingcare.org/">Saul Weiner
and Alan Schwartz</a>, who I have spoken about in previous posts, have looked
at whether medical records actually reflect what happens in an interaction
between doctor and patient and have found, by comparing tape recorded
encounters, and using standardized actor patients, that the record does
not! Thus even the data inputs from a
medical record, considered to be much stronger than the claims records have
serious flaws. They point out in their research that the medical records leave
out the emotions, competing priorities, financial concerns, spiritual beliefs
and other aspects of being human that have a major impact on the care
rendered. They call this contextualized
care and have found the ability to understand the person and not only the
disease is much more important in driving quality care than the purely
bio-medical issues. <o:p></o:p></div>
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Data tends to suffer from observational bias, sometimes
called the <a href="http://discovermagazine.com/2010/jul-aug/29-why-scientific-studies-often-wrong-streetlight-effect">“streetlight
effect”</a> from a joke that scientists like to tell. Late at night, a
police officer finds a drunken man crawling around on his hands and knees under
a streetlight. The drunken man tells the officer he’s looking for his wallet.
When the officer asks if he’s sure this is where he dropped the wallet, the man
replies that he thinks he more likely dropped it across the street. “Then why
are you looking over here?” the befuddled officer asks. Because the light’s
better here, explains the drunken man.
We tend to look at these big databases, designed and optimized for
financial purposes, because the light is better, even though the answers, the
insights, are more likely found in data ‘across the street’ where it is not
captured. <o:p></o:p></div>
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But advances are being made.
Lab data is now included in some databases. Pharmacy information, which used to be
separate, is now incorporated. Methods
using word search and mining audio databases of phone calls between providers,
patients, and insurers are starting to be used with some potential
effectiveness. However the databases, on a sheer numbers
basis, are still overwhelmingly claims or EMR based, both of which are designed
for financial and not clinical purposes.
<o:p></o:p></div>
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All this brings me back to the question which titles this
post. Is bad data better than no
data? I do not have a hard and fast
answer. Bad data can push you to make
bad decisions and when the data is big, the bad decisions can really be
whoppers. Big data used to identify
individuals is especially prone to mistakes as the variability in people is far
greater than can be seen from the financially based data in the databases. The danger is that we assume that the data is
correct. We assume it to be useful. Dr Jha takes exception to this and says, “The
burden is on proponents of the metrics to prove their usefulness.” Currently that is not the case and the burden
is on those who question the usefulness.
That does need to change and to be tempered by the medical tradition of
skepticism. </div>
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<o:p></o:p></div>
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None of this is to suggest that the use of data be
abandoned. Perfection is the enemy of
the good. Let’s just understand what we
are looking at, what the limitations are, and stop using even good data as if
it is perfect. We need to take a breath
and study the use of data to evaluate its effectiveness rather than assume that
all answers lie in those numbers. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-72570946923967399702015-10-08T04:54:00.000-07:002015-10-08T04:54:33.689-07:00Getting the Joke<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif";">Many years
ago, one of my children at a very young age was misbehaving and unhappy in
school. As two physician parents, we had
him assessed by a preeminent child and adolescent psychiatrist who lived in our
area. The late Dr. Sherman Feinstein was
at the time the editor of the Journal, Adolescent Psychiatry and had been a
faculty member at both the University of Chicago and the University of Illinois. When my wife and I, both relatively young
serious physicians would ask him for his diagnosis of our son, we would always
answer, “He doesn’t get the joke.” We
would of course be frustrated but he never wavered in that diagnosis. That son is now grown, successful and definitely
gets the joke. <o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";"><br /></span></div>
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<span style="font-family: "Arial","sans-serif";">Recently, another
one of my sons started a project in which he drives around the country interviewing
people to better understand the nature of spirituality in these United
States. His recent blog post was entitled,
</span><a href="http://www.spiritualfringe.com/"><span style="font-family: "Arial","sans-serif";">“On
Absurdity.”</span></a><span style="font-family: "Arial","sans-serif";"> He states, “So way down there in the trenches
of my belief is this incongruity, this inescapable absurd formulation of
believing at once that, yes we are all holy, knowing godly beings….but that we
are also Hobbesian animals, too often fighting and killing each other like
mindless unknowing brutes.” We, as
health care professionals, often give ourselves godlike powers even when we
understand that bad things happen over which we have no control and inevitably we will make mistakes and bad things will happen because we are human. The joke is that life is full of
irony and absurdity whether in health care or religion or everyday activities. That is just a part of our shared reality. <o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">All this
comes to mind due to a confluence of unrelated events. First, I have been traveling the past week to
speak at conferences (my previous two blogs were more directly related to those
conferences). The rooms were filled with
earnest young brilliant people who all had the answers to questions which have
both fascinated and eluded me for much of my adult life. Somehow I was both energized and amused by
watching them in their earnest certitude.
The ideas that technology, data and Internet solutions could be the
total answers to our health care questions seemed a bit absurd to me. Second, I have been writing a paper on
approaches to quality improvement which quotes the quality literature and the
goal of “zero defects” that I know to be theoretical but people often confuse
with something that is attainable with the right technology, the right data and
the right evidence based medical guidelines.
The idea that healthcare, with messy human beings who bring with them
complex diseases, complex social connections, differing values and cultures and
their own emotions and even dysfunction can ever reach zero defects is really
pretty funny. The third was a
conversation with a very close friend of mine who is a brilliant physician and
now has a cancer with a particularly poor prognosis. <o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">This friend
is someone who is always a bit depressed and overwhelmed by life. He and I live in different cities however we
speak regularly and it is often to give each other as hard a time as
possible. He is cautious, exacting, and
holds himself to an impossible standard of excellence that any other mere
mortal would see as ludicrous. Whenever
we speak he tells me of all the little annoyances that are getting in the way
of perfection and all of the different daily life issues that are clearly taking
his valuable time. I make fun of his perfection
in ways only close friends can. But not
this time we spoke. Now he spoke with a
calm and even happy tone that I rarely hear from him. All this while he told me that the studies he
has reviewed suggest his mean survival is unlikely to be longer than 31
months. The thirty one months is typical
of him. Not “between 2 and 3 years” but
thirty-one months. I commented on his
happy demeanor and he agreed. All of a
sudden all the small issues that would ordinarily annoy him seemed
meaningless. He got the joke. It may have taken him his entire life but the
happy news is that he now got it. <o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">The joke is
that we all make mistakes; we tend to believe we have more control than we
truly do, and that most do not accept or even realize that life is a fatal
disease. It is that life and work are
filled with paradox that cannot be reconciled.
It is, in the words of an elderly monk quoted in Yossi Klein Halevy’s
book, “At the Entrance to the Garden of Eden” that we must “Stand up for what
we believe in but leave the results to God.”
It is the old Yiddish saying that Man Plans and God Laughs. <o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";"><br /></span></div>
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<span style="font-family: "Arial","sans-serif";">We tend to
take ourselves, our work and our own pronouncements (like this blog) more
seriously than we should. </span><a href="http://www.benjaminzander.com/book/"><span style="font-family: "Arial","sans-serif";">Rosamund
and Ben Zander, in their book, “The Art of Possibility”</span></a><span style="font-family: "Arial","sans-serif";"> have a chapter dedicated to “rule # 6”
which is “don’t take yourself so goddamn seriously.” I know that I often do. I just then remind myself as I write these
blog posts, that I send them to the cloud with little knowledge of whether
people will actually read them. That
joke is on me. <o:p></o:p></span></div>
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<span style="font-family: "Arial","sans-serif";">This brings
me back to the meetings I attended last week with all of those earnest, smart
mainly young people. I think they need
to have more people my age and older attend.
I believe that if you survive into your 60s and still attend these types
of meetings, you are more likely to get the joke. Wisdom and experience may really be a
manifestation of understanding the irony of life. That perspective may help balance the sheer
enthusiasm of the young smart intense people who tend to gravitate towards
these difficult problems. Wisdom may be
defined by the understanding that no matter how serious our mission, and no
matter how intense our focus and efforts, if we don’t fundamentally get the
joke and take ourselves less seriously, if we don’t understand that success is
defined as trying to get closer to goodness even if we can never attain it, we
will end up locked into our own concrete paradigms and ultimately fail. And besides, if you get the joke, whether you succeed or not you can at
least enjoy all the effort. <o:p></o:p></span></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-64361798075100202462015-09-28T17:43:00.002-07:002015-09-28T17:43:45.925-07:00Breaking Down Barriers to Achieve Humanistic Care<div class="MsoNormal">
I write this while at 30,000 feet flying from the high tech
environment of Silicon Valley and the Stanford Medicine X conference to the suburbs
of Chicago for the Health Enhancement Research Organization (HERO) meeting. One
could not get more contrast going from the beauty of the Stanford campus and
their high tech auditoriums and lecture halls to the windowless conference
rooms of a suburban hotel. Yet the two
meetings are similar. Both are indicative
of the positive changes occurring in healthcare these days. We are starting to
break out of our concrete silos in order to address patient care from the
patient's point of view. It seems radical and that alone is indicative of where we have gone wrong up until now. <o:p></o:p></div>
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At Medicine X, many of the discussions were led by patients
or included patients who have found their voices through the blogosphere and
through organizations such as Accolade which help people become more empowered
patients. They are partners in their
care – patients who spoke of their own struggles to be seen as autonomous
individuals and not as diseases. At the session I moderated, Mary Reese, who
suffered with chronic pain for 11 years spoke about her frustration of having
physicians not believe her pain was real, dismiss her ideas and concerns, and
fail to find any solutions. To her credit, she always maintained respect for
those physicians and believed that they were acting to the best of their
abilities. Not once did she blame anyone for her predicament. Instead she spoke
of her struggles to be a good mother despite her difficulty just standing up
and walking and the loss of the ability to do all the things she enjoyed doing.
She then spoke of the human connection she was able to form with Karen, at
Accolade who in turn helped her find her voice and helped her find the right
medical resources to finally end the 11 year nightmare. <o:p></o:p></div>
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While the conference stresses technology, this year the
technology was presented as a tool to best be kept in the background with
patients like Mary in the foreground. The patients are using expert systems and
new approaches which are all but invisible to them so that simplicity can
reign. Mary was able to access the
skills of Accolade and the expert opinions of Grand Rounds, both of which are made
possible by combining technology and humanism in a powerful way. She is now
enjoying her life, free of the debilitating pain. She brought tears to everyone' eyes as she
expressed her love for her supportive husband and children who stood by her
during that dark decade of pain. <o:p></o:p></div>
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This dichotomy between technology and humanism is being torn
down as we appreciate the facilitating potential for technology within the
humanistic paradigm. Touching people as
people who have unique needs and wants and not as a set of symptoms or a
standardized disease is required to build trust and create effective care. The
newer approaches highlighted at Medicine X recognize this need to break the
shackles of old paradigms. <o:p></o:p></div>
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In the same way, at HERO, the emphasis has traditionally
been on prevention. Research to determine the best ways to effect improvement
in diet, stress management, exercise, smoking cessation, and other lifestyle
challenges to prevent disease has been the main focus. That focus has sometimes
created suspicion that it could create a tendency to blame the patient for the
disease. I have sat in HERO meetings with
groups that advocate for those with diabetes, heart disease, and arthritis
during which those activists rightly pointed out the danger of stating that
everything is preventable with the proper lifestyle approach. That “everything is preventable” myth could easily
lead to regulations, laws and benefit requirements that impose harsh penalties
for being unsuccessful in addressing behavior change as part of treating a disease.
<o:p></o:p></div>
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At this meeting however, I will take the podium with Dr Adam
Perlman, Executive Director of Duke Integrative Medicine and Associate Vice
President for Health and Wellness at Duke University Health System to discuss
how prevention techniques can be used effectively within therapeutics for
people with illness. We will challenge the model of every illness being preventable and instead offer a model which uses diet, stress reduction, exercise, and mindfulness both in the context of treating disease and for improvement of well-being for those without disease. Instead of treating the risk factor or the specific illness, new models will emphasize helping the person fulfill their own needs. We will present a new model in which the biomedical is combined
with an integrative model and an assistance model so that the patient point of
view, regardless of presence of illness, becomes paramount. The old silos
between prevention, wellness, and therapeutics must go. The concept of disease has to change as we
realize that our journey of life is dynamic.
Disease may be too static, too limiting, and may not adequately
recognize that the same disease may impact different people in different ways
at different times. We need to make these changes using technology but never
allow technology to get in the way of the person’s feelings, needs, beliefs and
values.<o:p></o:p></div>
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The fact is, unique individuals who get up every day, love
and care for their families, enjoy life and get sick must be
helped using every tool in the health, technology, medical and social arsenal.
They must maintain their dignity and their autonomy and be partners in all
efforts whether those efforts are preventive, therapeutic or supportive. They
cannot be forced to find fragmented programs and services through Internet
search or desperate attempts at networking. <o:p></o:p></div>
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We have a long way to go in breaking down the silos and
reaching the core humanism that must drive healthcare. The road will be
difficult as the voices of those who look for science, or prevention or technology
to be the only answer may dominate at times. However meetings like Medicine X
and HERO make me optimistic that we are moving in the right direction. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-71831297909630390592015-09-22T14:02:00.000-07:002015-09-22T14:02:18.821-07:00Medicine X and the Hopes and Fears of New Health Technology<div class="MsoNormal">
This week I am on my way to <a href="http://medicinex.stanford.edu/">Stanford Medicine X</a>. I will be moderating a session at this yearly
meeting of futurists in health care. Medicine
X describes itself as a “catalyst for new ideas about the future of medicine
and health care.” As described by the
organizers, “The “X” is meant to encourage thinking beyond numbers and trends –
it represents the infinite possibilities for current and future information
technologies to improve health.” For
this sixty-something year old physician, there is something about the term “X”
which suggests some meeting of Gen X, Star Wars and IBM Watson. I admit it the whole premise scares me as I
wonder if the technologies we talk about will improve health or suck the humanity
out. Can an app hold your hand and help
you feel less afraid as you face death and disability? At first glance, the humanistic and perhaps
even spiritual approach to medicine that I advocate seems to have little place
in a room full of young techies who still feel invincible and believe that
nothing will stop the inevitable march to automated utopian health care. Happily, I do know that assessment of this
meeting and the attendees is too simplistic, too glib, and yes maybe too jaded
to reflect reality. <o:p></o:p></div>
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One positive aspect of the health care tech and Internet
revolution is that it has the potential to give more voice to patients, the individuals
this medicine exercise is all about. At
this meeting, the voice of patients is heard with epatients, people
representing patient advocacy groups and others who come from the health blogosphere
who are present as full participants. The
session I am moderating will feature two physicians (me as moderator included),
a clinical psychologist and most importantly a <i>patient</i>. This is typical of many
of the sessions at this meeting and represents an approach that I welcome – one
that brings patients front and center in the discussions of the future of
medical care. It creates an atmosphere
in which the patient is not merely the recipient of care but a true partner and
ultimately owner of his or her own care.
In other words, this has the potential to democratize medicine.<o:p></o:p></div>
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In <a href="http://www.amazon.com/Lexus-Olive-Tree-Understanding-Globalization/dp/1250013747">Thomas Friedman’s book, The Lexus and the Olive Tree</a>
which he wrote in 2000, he describes three democratizations associated with
globalization driven mainly by the Internet – democratization of technology,
finance and information. Stanford
Medicine X represents a fourth democratization – that of healthcare. As we move away from the paternalism that marked
my generation’s approach to medicine, we struggle to find a new model that
gives more authority to patients, while not abandoning them to one-size fits
all self-service medicine. <o:p></o:p></div>
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Technology, thus far has not fulfilled that potential. Instead we have electronic medical records
that are designed to maximize hospitals’ ability to capture data for
billing. We have algorithm driven
systems that ignore the context of a person’s life so that the mother who must
choose between following a physician’s advice and caring for her child is
labeled a non-compliant patient. We have
data analytics systems that are technologically elegant that monitor physicians
for how they deviate from the guideline and punish them financially and by
reputation even if they deviate by following the patient’s needs – which may
not be medical. The technologies now in
use tend to restrict care and discourage the type of flexibility and individual
creativity that is so necessary to treat complex human beings with all of their
medical, emotional, and life needs. <o:p></o:p></div>
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Technology can be either restricting or empowering. “Can I move...I’m better when I move?” I still love that scene from "<a href="https://www.youtube.com/watch?v=_AoCK5r2TWg">Butch Cassidy and the Sundance Kid</a>", the classic Paul Newman, Robert Redford film. That scene represents the first meeting of
Butch and Sundance when Butch is testing Sundance to see if he should be part
of his group. He is asked to hold his
gun and shoot at a target. He tries to
move around however the person telling him to shoot insists that he “only shoot.” He misses.
He then asks the perfect question, “Can I move?” Butch’s assistant replies, “Move – What the
hell do you mean move?” At which point
Sundance shoots while moving and hits the target. Sundance then adds, “I’m better when I move.”<o:p></o:p></div>
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Some of us are better when we can bring our own voice, our
own style and our own approach to problems.
Indeed some physicians, while excellent clinicians, may rail against
technology driven systems that contain guidelines and algorithms which allow
too little room to move. The real
question in my mind as I head west to Palo Alto for the meeting is whether the
next generation of technology can better accommodate the challenges of treating
complex individuals while actually improving medical care, emotional support
and providing the social help that is so critical to health. I am
more optimistic when patients are involved in the discussions as they are at
this conference. <o:p></o:p></div>
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The meeting this year starts tomorrow which is also the
Jewish holiday of Yom Kippur. The holiday
is marked by asking forgiveness not only of God, but more importantly from all
those people we live with and work with.
In that spirit, I ask forgiveness from all of you. Because I see myself as part of the changes
that have been occurring in health care for more than a decade, I offer my
apologies for harm done and opportunities lost.
I offer apologies for the technologies that have led to more confusion,
less care and demoralization of patients and doctors alike. My hope for the coming year, starting with
Medicine X, is that we start to get it right and use technology to facilitate care
and foster humanism. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-2651527063437865722015-09-09T09:47:00.001-07:002015-09-09T09:47:49.646-07:00Quality Control and the Story of the Three Bears<div class="MsoNormal">
The story of The Three Bears is ingrained in all of us from
childhood. The little girl discovers the
house in the forest and finds three chairs, three bowls of porridge and three
beds. One is always too big and one is
always too small (or in the case of the porridge too hot or too cold) and one
is just right. It often feels that way
in health care as we try to find the right answer. Health economists and policy people will say
the problem is overuse – too much health care.
Patients often feel as though more can be done that is not being done –
too little health care. Finding the health
care that is “just right” seems to be an insurmountable task both for
populations and for individuals. <o:p></o:p></div>
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Two recent articles, one in a medical journal and one in the
popular press, both in narrative form, show us the challenge of defining
quality – the just right of health care – and ensuring it occurs. In <a href="http://archinte.jamanetwork.com/article.aspx?articleid=2429106">JAMA Internal Medicine, Dr. Jennifer DeVoe writes </a>about the care her father was receiving when at age 77 his
emphysema took a dramatic turn for the worse.
He was admitted to the hospital where the doctors, following the correct
evidence based protocols gave him oxygen, intravenous steroids and antibiotics They
were about to perform a bronchoscopy in the Operating Room which was the
correct procedure to diagnose the cause of this exacerbation although one
carrying significant risk as he would need to be on a ventilator and getting him
off the ventilator may prove to be impossible.
She asked her father how he felt about the bronchoscopy considering the
risk as well as the likelihood that he would not survive without it. When his daughter told him that he had a
choice and did not have to have the procedure, he said, “Let’s go home. What d’ya say?” They were about to do too much even though
the correct protocol said it was the right thing to do. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
They then transferred him to the in-hospital hospice program
as he was too unstable to go home.
Again, his daughter who is a physician managed to help him navigate the
shoals of a hospice team that wanted to stop his intravenous fluids as that is
the correct protocol to follow when someone is on hospice care. That was too little for this man who still
had some goals to achieve. To get it
just right, his daughter had to help him so the intravenous fluids would give
him enough energy to send birthday cards to his brothers and call friends and
family to say goodbye. By the end of the
week he had died on his terms with his daughter’s help. He did not have too much care or too little
care and he died receiving care that was just right. <o:p></o:p></div>
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The article from the New York Times, entitled, “<a href="http://www.nytimes.com/2015/09/06/opinion/sunday/a-doctor-at-his-daughters-hospital-bed.html?_r=0">A Doctor at His Daughter’s Hospital Bed,</a>” recounts the story of a father, an experienced
transplant surgeon, whose daughter is in the hospital critically ill. (Thank you to David Florman for sending this
article to me.) He sees that her pulse is elevated and her blood oxygen level
is decreased. The values had not yet
reached thresholds which called for immediate treatment of shock although his
experience told him that she was moving rapidly to a point at which therapy
might not even help. This experienced surgeon and father knew that
if he took no action he might lose his 17 year old daughter. Every protocol known to medicine holds that
the treating doctor, not a family member who is there, should be making
decisions such as whether or not to give fluids. However this father takes bags of fluids off
an emergency cart circumventing the normal processes and probably saves his
daughter’s life. He does all this with
the nurse calling her supervisor to complain about this irrational family
member acting against every hospital protocol.
But his daughter was receiving care that was too little and he stepped
in to make it just right. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
I must admit, that as a father I have sometimes found myself
in just that position of ensuring quality of care for a family member, often in
ways that do not easily fit the protocols and the standards. I have been accused by hospital staff of not
following protocol and have never been sorry about the actions I have taken for
my sons when I found it necessary. (I
have written about these situations in my blogs previously <a href="http://www.healthwealthandlife.blogspot.com/2013/05/lessons-learned-at-academic-medical.html">May 2013</a> and
<a href="http://www.healthwealthandlife.blogspot.com/2014/11/surgery-family-and-post-operative-care.html">November 2014</a>) I identified strongly
with Dr. Bud Shaw as he protected his daughter from the norms of the medical
system. Those norms can often be
uncompromising and even uncaring when flexibility and care should be
paramount. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
Both of these stories reflect the difficulty of ensuring that
every person receives care that is just right for them. It sometimes takes an understanding that
protocols and guidelines are designed to be flexible and must be used in a
customized way for each patient. In
order to do that, the health care professional must be constantly thinking
about how the protocols may and may not apply.
<o:p></o:p></div>
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<br /></div>
<br />
<div class="MsoNormal">
The unifying aspect of these stories is a commitment to the
patient that is more than only a professional responsibility. The stories reflect a customization of care
that requires knowing more about a patient, as Jennifer DeVoe puts it, and also
caring more about the patient as a person and not only as a disease. They reflect a need for a family-like
commitment to the patient. While I do
not expect, nor advocate that a family member be the patient’s physician, I do
advocate following the old medical saying that every patient should be treated
as though they are a loved family member.
Medicine of the highest quality must be a calling, not only a craft or a
profession. We must find ways to measure
and ensure that element of customized care and not depend on adherence to
specific protocols as the arbiter of quality so that the care rendered is
always “just right” for that unique individual in need. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-57690476259645878232015-08-30T08:47:00.000-07:002015-08-30T08:47:00.345-07:00Medicine, Politics, and the Individual Patient in Need<div class="MsoNormal">
My friend, <a href="http://millenson.com/">Mike Millenson</a> recently “tweeted” a link to a
heart wrenching story by a physician in Australia that deserves to be read by
all concerned with patient care. <a href="http://www.theguardian.com/commentisfree/2015/aug/03/a-letter-to-my-patient-whose-terminal-cancer-is-the-least-of-her-worries?CMP=share_btn_tw">Dr.Ranjana Srivastava tells a story of discovering the true person behind the disease </a>as she treats a woman who has metastatic pancreatic cancer who speaks
no English and is awaiting word on her asylum request to stay in Australia. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
The story has many levels.
At one level it is about the physician who starts out annoyed by the non-English
speaking patient who is missing appointments for her chemotherapy. It moves into hearing the story through an
interpreter of the patient being a former teacher, escaping from a war zone
with two small children, after her husband had been killed. It then moves into the struggles of being a
refugee in a strange country, trying to work through the system to take care of
her children, while addressing her own probably terminal illness. The author eloquently defines the woman she
is treating as one who is “cursed first by geography and then illness” as she communicates
a subtle political message about the plight of refugees. She writes, <o:p></o:p></div>
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<br /></div>
<blockquote class="tr_bq">
“You see, most of my friends, even the professional ones,
have never met a refugee – they form their views from tabloids, and the
increasingly shrill sound bits of politicians.
But the thing is, when I look at you, I don’t see a queue-jumping,
illegal, unauthorized, undocumented alien or for that matter, any of the names
used to strip you of your dignity. I
only see a thoughtful woman, a loving mother and a vulnerable patient, with no
husband and two young children…”</blockquote>
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<o:p></o:p></div>
<div class="MsoNormal">
The story then ends with the physician returning to the
safety of what she knows best and is trained to do. “We return to your pain…” The end is one of the powerlessness of
medicine in a world that treats refugees poorly. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
I empathize with the politics. I am the children of immigrants – refugees
from Europe – who escaped the horrors of the pogroms and the Holocaust which
was the fate for Jews in Europe in that era.
I do believe that we need ways to help those who must flee their native
lands to find new and better lives for themselves and their children. We must find policies to welcome those who cross
borders; even crossing oceans for a chance and make them part of our own
societies. But I do not have the answers
for the complex questions that are part of the dilemmas that governments face
as they try to develop answers that are humanistic and also protective of the
people they serve. I recognize that
there are rarely simple answers to these questions. I am a physician and I must help people in
their reality, not in the reality I wish them to be in. I understand the desire of the physician who
writes this as a clarion call to be more welcoming to those people who become
refugees through their own courage and fortitude rather than any
malevolence. However we also must speak for this particular
woman in need right now. Changing policy and changing attitudes takes
time and this woman with children who has an awful illness has no time. Powerlessness and a return to the purely
medical need not be the default for physicians.
<o:p></o:p></div>
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<br /></div>
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Therefore while I sit in awe at the writing ability of the
physician, and am truly touched by the patient’s story, I can’t help but
believe that it misses a critical element.
That element is what this woman, who has a horrible disease that is
likely to kill her, really wants and what her goals truly are. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
The physician has started to know who this person is, with
the help of an interpreter however in this article she has yet to get past the
refugee’s story to the person’s real hopes and dreams at that point in time. I can
try to guess based on all this woman went through to get her children safely to
Australia. I suspect it has to do with
building a better life for her children.
I want to know what the physician might do to help that woman meet her
goals and make a better life for her children even if she succumbs to the
disease, as it likely. I want to know if
the physician can get past her own comfort level, dealing with chemotherapy,
pain management, and the like to address issues such as the help the woman may
need in shopping for food, getting her children to school, and planning for her
children’s care after her death. <o:p></o:p></div>
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<br /></div>
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I know that the physician may not be the correct person on
the health care team to address all of these issues. Other team members may need to take the lead
to find ways to help the patient with these life difficulties. However
the physician should note that these important life issues may have priority
over pain, disease and treatment protocols for that patient. The starting point for all this must be
asking the patient what her hopes and dreams really are as the most valid goals
are the patient’s own.</div>
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<o:p></o:p></div>
<br />
<div class="MsoNormal">
Thus while I want physicians to take political stances as I
believe all citizens should, and I want them to be skilled with the biomedical
aspects of care, I especially want physicians to know who their patients are as
people, as unique individuals and understand the patient’s values and
goals. I want physicians to focus on
helping people through the difficulty of illness even if other healthcare team members
take the lead in addressing those legal, social, psychological, financial and
logistical issues. I want every
physician who sees a patient to also see the whole person and address all the
issues that impact the person’s ability to deal with their life as disease gets
in the way. That is what defines medicine as the calling
it is and should be. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-7794150686766123882015-08-19T08:04:00.000-07:002015-08-19T08:25:44.908-07:00It’s the Little Things that Matter: Fighting Logistical Toxicity<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">Many people struggle with the life issues and the small decisions
that occur every day when one is dealing with an illness or a family member’s impairment. Whether financial issues related to the
medical bills, attempting to make sense of insurance statements, trying to
figure out who will walk a dog when going for a test or therapy, or just
balancing a job schedule with appointments for doctors, the challenges are real
and affect the quality of care and the cost of care. All this is true whether you have a critical
illness, a chronic disease, or an acute “minor” problem (I always teach that a
minor illness is something someone else has and that everything I or someone I
love has is major). <o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Most attempts to address high health care costs do not
address these small decisions that, in aggregate, have an outsized effect. Current paradigms in the quest to lower
health care costs usually ignore this approach of addressing the small everyday
life disruption of all illness. In the
healthcare and health benefits world, we are told that focusing on the 20% of
people who generate 80% of disease costs or people spending healthcare dollars
in the last six months of life should be the focus. Yet focusing only on the 20% of people and
those in the last six months of life means we ignore many who are in need and
who are flailing around a confusing and often impersonal system. We are told that computer medicine driven by
Dr. Watson from IBM is the answer and that the best doctor is a computer. But computers cannot comfort someone who is
dying or understand that an evidence based guideline that requires one to have
daily therapy instead of picking up children at school is untenable. Current
paradigms often imply that the problem is that doctors don’t follow evidence
based guidelines or patients are not doing what they should be doing. Yet assuming doctors don’t know what to do
and that patients are not acting in their own best interest is likely to be an
overly simplistic and false assumption. <o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">We need new paradigms.
Often the issues are a lot smaller.
Like the man who could not go into the hospital for his worsening
congestive heart failure because there was no one available to feed his cats,
or the single mother who could not go to a specialist appointment for her
worsening diabetes because she could not afford to lose another day of work since
she had used up her sick time when her children had the flu, or the gentleman
who went to the ER for a sore throat at 2 AM because his only free time while working two
jobs is between midnight and 6 AM. <o:p></o:p></span></div>
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<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">The right paradigms should address how to eliminate <i>unnecessary</i> health care costs and look
at the world of health care through a patient’s eyes – a patient who has a
family, friends and other priorities that are not health related. The right paradigms should look at what
really drives doctors and patients to make decisions that may drive up costs and
bring little or no value to patients and families. </span><span style="font-family: Arial, Helvetica, sans-serif;">Perhaps the real answer is to create new ways to look at the
problems. </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">In a <a href="http://www.forbes.com/sites/elaineschattner/2015/08/14/logistic-toxicity-an-unmeasured-burden-of-health-care-for-people-with-cancer-and-other-illness/">recent
post in Forbes, Elaine Shattner uses the term, “logistical toxicity”</a> (first
coined by Shelley Fund Nasso of the National Coalition for Cancer Survivorship)
to describe the ill effects that the “administrative burden of healthcare” has
on patient care and on cost. While the
article focuses on cancer care the logistical toxicity is seen with all
illness. These administrative burdens,
and the competing life priorities that are often even more important, are
difficult to manage when one is ill. Physicians and other health professions cannot
be expected to help with these life issues as they are ill prepared to
recognize and address those factors.
Elaine Shattner in her post says, <o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="margin-left: .5in;">
<span style="font-family: Arial, Helvetica, sans-serif;">“Chores – like processing medical
bills, holding on the phone for providers, filling out and submitting paperwork
to insurers – can chew at a healthy person’s time, causing annoyance. For someone who’s chronically ill, these
tasks and additional, long-term responsibilities – coordinating frequent medical
appointments, and arranging for time off at work, and for childcare or
caregiving of another adult – compound the physical and financial toll of
disease.”<o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">It also goes beyond the chores themselves. Those increased burdens and those competing
life priorities create tremendous emotional turmoil and can cause a sense of
social isolation. One feels as though
there is no one to help, because the benefits and the health delivery systems
have become so disjointed that they cause headaches instead of help. As Ms. Shattner says, “The potential failure
to take care of everyday tasks can lead to feelings of defeat or helplessness,
besides exhaustion.” Your doctor does
not really understand your health benefits, and may or may not even ask you
about the life challenges that are getting in the way of the treatment of your
illness – that logistical toxicity. Your
healthplan is willing to help you understand your benefits and claims, but not
deal with the life issues that are sitting in the background affecting everything
else. <o:p></o:p></span></div>
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<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">When we started Accolade, we realized that the health care
system had become so complex and so difficult to deal with that it could be
dangerous to people’s health and could actually increase costs. As we looked into the problems from a patient’s
point of view, we found two parallel systems at play – a health benefits system
that was attempting to put incentives, rules and regulations in place to police
care, and a health care delivery system that was attempting to become more
efficient and of higher quality by a division of labor approach in which higher
paid team members, such as physicians, were only involved in activities that
made the most of their expensive time. The
algorithms driving care were designed to prevent errors and theoretically
improve care. However, from the
patient’s point of view, all this created fragmentation and a movement towards
“one-size fits all” medical and health benefits approaches with its associated
depersonalization. If you didn’t fit in
to the rules and algorithms, you suffered.
The paradigms for efficiency, we found, were often contributing to
inefficiency and lower quality care from the patient’s perspective. Those paradigms that were being used were often
not helping people in need. <o:p></o:p></span></div>
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<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">We decided to create a new approach and a new profession
based on a belief that <i>all </i>people
with illness of any type need help, not just those people with high cost
complex illness. Our hypothesis was that
costs would be lowered by immunizing against logistical toxicity, and
supporting people through the emotional roller coaster that is associated with
illness. We tested whether we could
impact the changes in the social structure of family and the life challenges
that are associated with illness of any kind.
<span style="background: white; color: #222222;">All illness, even “minor”
illness can be disruptive and interfere with life context while inducing
fear, sadness and anger. So we built databases, trained professionals to deal
with this toxicity, and developed operational processes. In a sense we
went about building immunization, antidotes and treatments for logistical
toxicity and the social and emotional toll it takes. We knew that this was not a simple problem
but something that demanded a new profession based on trust, with specific
expertise and the support of proper data and information systems.</span><o:p></o:p></span></div>
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<span style="background: white; color: #222222;"><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">We determined early that just solving the problems as they
occurred would not be effective. We had
to provide ongoing assistance to help people avoid these problems in order to
be able to solve issues early so their toxic effects would not multiply and
become petrified and even more difficult to reverse. We learned that when people are faced with
logistical toxicity, they develop suspicion and lose trust in the system to a
point at which it is hard to overcome.
We found that we had to form trust early in the process and even before
the problems occurred. <span style="background-color: white; color: #222222;">In the 8 years since starting this new
model, we have proved it works – costs are lower and from a patient’s point of
view, care is better.</span></span></div>
<span style="background: white; color: #222222; font-size: 11pt;"><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span>
<span style="background: white; color: #222222; font-size: 11pt;"><span style="font-family: Arial, Helvetica, sans-serif;">I am fundamentally optimistic about health care
as long as we continue to challenge existing paradigms. I believe that our initial experiment at
Accolade, and other similar approaches that address patients as people and not
diseases, will become the norm. New
professionals will help address all of the challenges of illness, not only the disease
pathology, providing value from a patient’s point of view. We will continue to find new approaches that
will eliminate the scourge of logistical toxicity. Most importantly, we will not allow health
care to become so rigid that it ignores the infinite tapestry of our diverse
population and the unique life issues that each person brings. </span></span>Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-65853637318198079812015-08-10T06:41:00.000-07:002015-08-11T06:13:51.592-07:00Confusing Populations with Individuals in Health Care<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">The doctor patient relationship is a sacred one that is
ultimately driven by a person in need, putting their trust and even their life
in the hands of a health professional. The
bond between a doctor and a patient is formed with the expectation that it will
be met by total dedication to the patient’s well-being by the health
professional. However, in recent years,
physicians, nurses and others in the caring professions have been challenged to
take a broader societal, or population view of those they serve, especially
when it comes to cost. Our current high cost of health care can limit needed access to care with the burden often falling on portions of our population
who are the most at risk for health problems. Who better to address this
than the health professionals who care for people, so the argument goes. The theory is that the population view,
especially when taken by individual health care providers, will provide more equity
in health care and better treat all those in need. The physician and the health care team then
becomes the steward of the health care dollar for our society as well as the
caring agent focused on the patient. But
is this an appropriate role for the physician?
Do these newer efforts towards placing societal costs in the equation of
“best medical care” for an individual risk creating a system in which
physicians have more responsibility to their particular system or to the total
society than to the actual people in their care? <o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">The <a href="http://www.sciencedirect.com/science/article/pii/S0735109714016842">American
College of Cardiology and the American Heart Association (ACC/AHA) have just
published a joint statement</a> on cost/value methodology in clinical practice guidelines
and performance measures. They have tried
to thread that needle of societal needs for cost control and individual patient
care. The result is a properly nuanced approach that
acknowledges the difficulty of the task as well as the current reality that the
challenge cannot be ignored. They note, in their executive summary that “from
a societal policy perspective, a critical healthcare goal should be to achieve
the best possible health outcomes with finite healthcare resources.” They further note that “individuals bear the
burden of adverse health outcomes, yet costs typically are shared by society
(e.g., by families, employers, government, premium payers, fellow employees,
taxpayers).”<o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">All true. Yet what should
the role of the physician be? And how should
guidelines from esteemed organizations such as ACC and AHA address these issues
when they set standards for individual care?
Should the physician follow a guideline that directs the care they
render to be influenced by the fact that the treatment may not be of high value
to the payer even if the doctor and patient believe it to be high value in that
particular case for that particular patient?
Perhaps a bigger question to ask is whether the patient should trust a
doctor if the doctor is being driven by a societal equation instead of an individual
patient equation. Ultimately, this is a question
of whose interests – society’s or the patient’s – are paramount when the
medical decisions are being made. I
believe that in all cases the physician should focus on the individual patient’s
interests for that is the essence of medical care. While
societal costs are extremely important and must be taken into account when
setting health policies for a nation, there is something different that is
going on when a patient is in an exam room with a doctor, a nurse, or another
health professional. That difference is
the sacred trust when one person opens themselves to another in the hope of
being cared for when in a time of need. <o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">But there is often less conflict here than may be apparent. When the patient’s values and goals are
paramount, cost often enters into the equation – it just isn’t the societal
cost but the individual cost. Physicians
today are not very good at assessing their patient’s goals, needs and values when
they are outside of the purely clinical. When those individual goals enter the realm of
finances, competing priorities (such as taking care of people they love), or
the patient’s spiritual needs and beliefs, as evidenced by <a href="http://www.contextualizingcare.org/">research done on context by Saul
Weiner and Alan Schwartz of the University of Illinois</a> over the past
fifteen years the physicians’ ability to recognize, assess and address those
needs is poor at best. We know that <a href="http://mdm.sagepub.com/content/early/2015/07/16/0272989X15594382.abstract">patients
assess the treatments recommended by physicians based on their own internal
equations</a> and cost is often a component of those individual decisions. The good physician, who forms a true trust
bond with the patient, must take that all into account. When that happens, total societal costs are
more easily controlled, as has been previously suggested in a <a href="http://qualitysafety.bmj.com/content/early/2012/07/06/bmjqs-2012-000832.short">study
done by Weiner and Schwartz in assessing the costs of “contextual” errors in
health care</a>. We see that at Accolade
as we help patients address their life needs, find their voice and communicate
their goals to their doctors, nurse and therapists and see total costs go
down. <o:p></o:p></span></div>
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<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">It is clear therefore that, as the ACC/AHA statement
suggests, that “the need for greater transparency and utility in addressing resource
issues has become acute enough that the time has come to include cost-effectiveness/value
assessment and recommendations in practice guidelines and performance measures”
but the inclusion of “performance measures” does worry me. If doctors are judged by their ability to
meet societal standards of cost effectiveness will that change the
doctor/patient relationships and the agency that the doctor now has for the individual
in their care? We clearly need more transparency
and we must be able, as health professionals to translate that cost information
into useful knowledge to help patients with their decision making however our
performance measures should be based on how well we address those individual
health care cost needs and the value for that individual. That is different than being measured by how
well we meet the societal goal of lowering health care costs.<o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">The ACC/AHA statement does address how these guidelines are to
be used and makes the statement that “the value category should be only one of
several considerations in medical decision making and resource allocation.” But resource allocation for one patient is an
entirely different issue and must be based on the patient’s values, not the values
of the physician or society. In the
published article, the ACC/AHA committee rightly states that “Care is of high
value if it enhances outcomes, safety, and patient satisfaction at a reasonable
cost. Care is of low value if it
contributes little to outcomes, safety, and satisfaction or incurs an inappropriately
high cost.” I would add the words “from
the patient’s perspective” to those words.
Ultimately, we must understand that as physicians – as health
professionals – we are servants to and advocates for those in need and we must
define outcomes, safety, satisfaction and even costs from the patient’s point
of view. Until we develop guidelines and
performance measures that understand and acknowledge that fundamental agency of
the health professional for the individual patient, we will neither save money
nor improve care but will only erode the trust that is the cornerstone of
health care. <o:p></o:p></span></div>
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Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-80597316070474646302015-07-27T05:51:00.000-07:002015-07-27T05:51:04.672-07:00Challenging Paradigms: Practicing at the Top of Your License<div class="MsoNormal">
The industrial revolution has come to healthcare. Old paradigms – from routine physicals to
even the concept of the doctor as the captain of the ship – are being
challenged as we try to find more efficient ways to deliver high quality care. However as fast as we break down the rigidity
of past practices in order to foster better systemization we seem to build new
paradigms that may have negative unforeseen consequences. These new “truths” can rapidly be set in
concrete while the problems they create are given little attention. We must always be asking ourselves whether we
are truly improving care or if we are merely swinging the perennial pendulum of
change too far as we try to reject shibboleths of the past. <o:p></o:p></div>
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A new paradigm that I see in many realms of medicine is the
concept of having each professional practicing at the top of their license and
their training. What that means is that a
doctor should not do something that a nurse practitioner can do; a nurse practitioner
should not do something that a nurse can do, and a nurse should not do
something that a nurse’s aide should do. In practice this concept has
manifested in a variety of ways. During
my recent hospital stay <a href="http://www.healthwealthandlife.blogspot.com/2015/06/my-recent-hospital-stay-and-care-of.html">which I described in a different blog</a> post, the nurses
rarely touched me or even saw me as they stayed at the nurse’s station
monitoring my cardiac rhythm, watching my trends on the computer, and only
coming in to give me medications twice a day.
The nurses’ aides took my vital signs, helped me get to the bathroom and
changed my bedding. The doctors did not
come in at all as they were able to access the record from multiple locations and
I only saw the physician at the time of my procedure. In psychiatry, this same concept has
developed to the point at which it is unusual for a psychiatrist to engage a
patient in talk therapy and instead is involved mainly in medication management
with talk therapy being performed by licensed therapists who are not MDs. For surgeons, it means that they are often
focused totally on their work in the operating room with nurse practitioners
assessing the patients and caring for them before and after the surgery. <o:p></o:p></div>
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The fact is that this type of approach has some attractive
features. For the system, it could
potentially save money. For the health
professional, it frees them from doing tasks that they may not like to perform
and allows them to focus on the tasks they are trained to do. But is this
better for the patient? Is this strict
division of labor really conducive to high quality, patient centered care? <o:p></o:p></div>
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In some ways, this new paradigm is related to the industrial
revolution that health care is now undergoing.
The assembly line was a key component of the industrial revolution of
the nineteenth century and the movement towards a new industrial revolution in
health care can be seen to be following that tried and true formula. A true division of labor approach in which everyone
limits their practices to the top of their license and training has
advantages. Assembly lines allow for
specialization of roles and that often leads to less variability which is associated
with higher quality products being produced at a significantly lower cost. The cost of labor goes down as each person
involved only performs a small number of tasks.
That allows for training requirements to be narrowly focused as well,
with the jobs themselves then more easily filled at a lower salary level. If more can be done by nurses’ aides who are
lower paid than nurses, the theory goes that nurses can focus more on the “important”
nursing roles which results in a decrease of total costs and a more effective
and efficient system. <o:p></o:p></div>
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However the disadvantage of the assembly line is that unique
craftsmanship is lost. From the worker’s
point of view, the work becomes repetitive and the “big picture” of the ultimate
goal, complete with individual pride of reaching that goal is lost. The individual ownership of the product (and
in health care the product is the well-being of the patient) risks being lost in
a system that is based on assembly line principles. There is a reason that the finest products in
the world are often not made on an assembly line but are made by master
craftsman who take great pride in their work.
We see some of these disadvantages in this new medical paradigm as
physicians and nurses are rewarded for how well they do their individual tasks
rather than how well they treat the whole person. <o:p></o:p></div>
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Medicine is filled with the risk of low probability and high
consequence events, some of which are due to our treatments and not only to the
underlying disease. Quality medical care
demands anticipating and avoiding those events and treating people in such a
way as to minimize the risk of any intervention. That may require more holistic thinking about
the patient rather than task based thinking.
A health professional who is very hands-on even if that is “below” their
training and license may be the best defense against poor quality care. <a href="https://www.propublica.org/article/surgery-risks-patient-safety-surgeon-matters">A recent article in ProPublica</a> that focuses
on surgery risks and patient safety makes this point when they describe two
surgeons in a small community hospital in northwest Alabama who are among the
best in the country at doing joint replacements. Dr. Aaron Joiner and Dr. John Young have
performed 282 knee and hip replacements over the last five years with zero complications. The way they accomplish this is the
antithesis of practicing at the top of your license. As described in the article, they often
operate together even though that hurts their income. They believe that having two surgeons in the
operating room provides a backup and an immediate quality control. They describe a typical interaction in the OR
as one in which they are open and honest when they see their partner doing
something that does not measure up to their own standards. “I may look at something a little backwards
or get turned around,” Joiner said. “It’s
nice for one of your partners to say, ‘What the hell you doing? You’re not out huntin’ this morning. You’re doing a knee replacement!” They also do all the post up care themselves
rather than having physician assistants or nurse practitioners do that for
them. As Dr. Joiner puts it, “We don’t
cut corners. We do it the right way
every time.” <o:p></o:p></div>
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I remember when I was training in gastroenterology, serving
on the service of Dr. William Silen, a giant in the world of surgery, who was
also a dedicated teacher, mentor and patient advocate. At Harvard Medical School, the William Silen
Lifetime Achievement in Mentoring Award honors his leadership and his
memory. We would make our rounds with
Dr. Silen to see patients at 5 AM every morning and at 6 PM every evening,
personally seeing each patient pre and post operatively twice a day with our
operating room duties in between. The
fellow or resident who just wrote an order without actually seeing the patient,
talking to the patient, and examining the patient would not last long with Dr.
Silen. The doctor in training who
thought that removing a naso-gastric tube or changing an intravenous line was a
nurse’s job and not his or her direct responsibility would quickly learn that
attitude was not acceptable. For Doctor
Silen every task that involve caring for a patient was in the physicians scope of
practice and was, by definition practicing at the top of their training and
license because medicine was about ownership of the entire patient – their problems,
their hopes and their lives – not about the specific task that needed to be
done.<o:p></o:p></div>
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The idea that all health professionals practice at the top
of their training and license when used in the context of a true team all
sharing full accountability for a patient can help both quality of care and the
human caring that patients need. However
it is very easy for that pendulum to slip past the midpoint into the realm of
assembly line care that focuses on the immediate task rather than the entire
patient and their family. In an age of
ever expanding health systems, employed physicians, corporate medicine, government
medicine, and large mega-health benefits companies, it is far too easy to focus
on an assembly line mentality rather than a team mentality that can truly
improve care. Let’s not allow the new
paradigm that demands division of labor to ever divert us from the idea that
all care for a fellow human being in need is by definition at the top of one’s
training and license. <o:p></o:p></div>
Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0tag:blogger.com,1999:blog-4102811049352281954.post-41034002725687284292015-07-09T06:21:00.000-07:002015-07-09T06:21:07.877-07:00My Recent Hospital Stay: Getting the Joke<div class="MsoNormal">
I was home following my hospital stay, trying to modify my
lifestyle and attempting to adjust to new medication to help me deal with my angina
(chest pain due to heart disease) when the 5 page letter, using words that only
a lawyer could love, came from the health plan.
<o:p></o:p></div>
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“<i>We have reviewed information received about your care and
specific circumstances using the MCG criteria for Inpatient and Surgical Care.
Based on this review, coverage for the requested admission is denied.</i>” <o:p></o:p></div>
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Happily I did not take the denial letter seriously. If I had I would have been at risk for
readmission to the hospital with more chest pain and shortness of breath. My first reaction was to think this was
extremely funny. I know how these issues
work, and also know that my diagnosis of unstable angina (increasing chest pain
related to heart disease while on medication) with an abnormal stress treadmill
test fit criteria for coronary angiography, an invasive procedure to see my
coronary arteries. I had, indeed already
received health plan “approval” for the cardiac procedure. I also knew that the best practice algorithm from
the American College of Cardiology, for unstable angina called for “admission
to the hospital for bed rest with continuous telemetry monitoring.” All that had happened correctly. I assumed that somewhere along the line,
despite more attention being given to documentation than to actually doing
anything (see my last blog post), something had been lost in translation. My cardiologist, a very exacting person when
it came to do a cardiac procedure was perhaps less exacting when it came to
filling out the paperwork. The hospital
department that submitted the documentation may have missed the boat in
communicating what was really happening in my life when I was forced to enter
the hospital – a step I loathed taking. <o:p></o:p></div>
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But then I stepped back.
What if I had received that letter and did not have the knowledge I
had? Would I believe that my doctor did
something wrong or did not treat me correctly?
Would I curse my health plan and accuse them of being uncaring and
incompetent? Would the anxiety of
potentially getting a huge bill I could not afford create more stress when I
was trying to deal with the stress of having ongoing heart disease? And would I believe that MCG criteria were
some magical code that determined whether I would live or die? <o:p></o:p></div>
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My knowledge of the facts made me see the humor in this and
not be stressed by the game of telephone that occurs when physicians and
hospitals try to communicate medical needs to the health plans. I knew that MCG stood for the Milliman Care
Guidelines first developed by an old friend, Richard (Dick) Doyle who was a
brilliant physician and consultant when he worked for Milliman, a respected
actuarial consulting firm. I used to
joke that the first generation of the Milliman guidelines were made up by Dick
Doyle with his feet up as he looked over the Pacific Ocean in his house in San
Diego rather than by any scientific method.
It felt like the use of only the initials, in the denial letter, made
these guidelines have so much more weight than they really were meant to have –
making their use in the denial letter almost comical. Milliman
Care Guidelines are used by many health plans and even by government plans to
judge efficiency because of their operational ease, not because of their
scientific rigor. They are not meant to
be nuanced and rather are guides to what can be achieved in the perfect world
that those who practice clinical medicine rarely see. My cardiologist, who admitted me and did the
coronary angiogram, was well trained, smart and caring and did everything right
clinically. The people in the health
plan were all caring professionals trying to uphold the plan requirements in a
fair way. All these people are good
people doing the right thing and yet the letter that was sent to me seemed to
say that my care had been wrong and would not be paid by the health plan. It was communicated to me, the patient, in a
heavy-handed way that said that what I had done was “not medically necessary”
according to those magical guidelines. <o:p></o:p></div>
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Upon further investigation, I discovered that the contract
that the health plan has with this hospital calls for these admissions for
unstable angina to be billed as observation unit days, rather than
admissions. I was lying in a bed in a
room as an inpatient and this contracting fiction that drives payment was
meaningless both to me and to the hospital staff who cared for me (or who cared
for the computer as I speak about in my previous blog). I, as the patient, will be held harmless and
not have to pay for this purported mistaken admission driven by my acquiescence
to supposed “sub-standard” care since the mistake did not occur and the denial
was just due to the financial relationship between the health plan and the
hospital. Now that my investigation is done, which I took on as a form of
entertainment, I will go back to focusing on my own health issues. <o:p></o:p></div>
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The good news is that my cardiac procedure did not show any
critical lesions but instead showed disease that is readily managed by
lifestyle modification and proper medication.
I am also fortunate to appreciate the irony of the whole episode. I get the inside joke that others may
not. My goal is for everyone to have someone
at their side who also gets the joke and who is able to understand health care
and health benefits. That person – in my world the Accolade Health
Assistant – knows how to navigate the system and help people through the
decisions, the documentation, and even the denials when they come. I don’t want anyone with heart disease or any
other medical issue to be at risk for new medical problems due to “payment fear”
related to accessing health care just because they don’t have my knowledge. Everyone needs a health assistant and with
the experience gained from this medical interlude, I will continue my efforts to
make that happen. <o:p></o:p></div>
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Alan Spirohttp://www.blogger.com/profile/05169093832905933877noreply@blogger.com0