Behavioral Economics and Patient Engagement

I recently had the honor of sharing the podium with Bob Ihrie, Senior Vice President of Comp and Benefits at Lowe's Companies.  The Conference Board held their 15th Annual Employee Health Care Conference in New York where Bob and I spoke on the drivers of change in health care.  Please click on this link to see our presentation and the questions that followed.  The entire video is about 45 minutes with the presentation itself taking about 30 minutes.  

Complexity for Doctors and Complexity for Patients

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

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

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

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

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

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

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

The Loss of a True "Mensch"

On March 1, 2015, the world lost a true mensch and a tsaddik, a righteous man.  Dr. Wayne Katon, Professor of Psychiatry and Director of the Division of Health Services and Epidemiology and Vice Chair of the Department of Psychiatry and Behavioral Sciences at the University of Washington Medical School died after a long battle with lymphoma.    He was internationally renowned for his research on anxiety and depressive disorders in primary care, the relationship of psychiatric disorders to medically unexplained symptoms such as headache and fatigue, and the impact of depression and anxiety on patients with chronic medical illness.   Through his career he developed innovative models of integrating mental health professionals and other allied health personnel into the provision of medical care to improve overall care and directed a National Institute of Mental Health funded National Research Service Award Primary Care-Psychiatry Fellowship that successfully trained psychiatrists and primary care physicians for leadership positions for over 25 years.  He was also a member of the Medical Advisory Board at Accolade and contributed to our combined medical-psychosocial-financial model that helps people as they deal with the illnesses they face. 

I use those two Yiddish words, mensch and tsaddik, to describe Dr. Katon because for all his academic accolades and credentials, what stands out for me was his goodness and humanity.  Those two words are independent of any religious implications and are just better descriptors than any words I could find in English of that essential goodness.  The definition of a mensch in English is an upstanding, worthy honorable adult person of either sex, even though the word mensch literally means man or human being.  A tsaddik is defined as a righteous person.  There is a story in the Babylonian Talmud that states that the world requires 36 tsaddiks, righteous people, for the world to survive at any point in time.   Wayne Katon was one of those righteous people whose goodness kept this world going.  He is survived by his wife and childhood sweetheart, Bobbi Geiger, their two daughters, and four grandchildren.  He is also survived by all of those people he fathered and grandfathered through his clinical care, teaching and writing as he made this a better world.   

Paradox and Focus

I have just spent two days at the Conference Board’s 15^th Annual Employee Healthcare Conference.  The speakers were the leaders in an evolving world of employee health benefits whose goal is to improve the world of healthcare and healthcare benefits that large employers make accessible to their employees.  These speakers were both representatives of the companies that serve (and sell to) employer’s health benefit programs and the representatives of the corporations who are responsible for managing the funds available for health for their employees and the employee’s families. 

As I listened I was often struck by the specific lens through which the speakers were offering their solutions.  There were physicians who developed and put forth programs on their specific areas of expertise.  This ranged from offering physician services over the Internet in a telemedicine mode to offering high level academic medical type services as second opinions to offering a specific program for a specific condition or set of conditions such as diabetes, heart disease, and others.  There were the business leaders of these companies, with their sales focus, who tried to show how their solutions would save the employers money while potentially improving care and helping the employees be healthier and more productive.  And finally there were the employer health benefits people whose lens was the budget that they must meet while also meeting the commitment they have to their employees.  Their goal is often the hardest as they must find a way to lower costs and bring tools to bear to also improve productivity, and increase the employee’s sense of attachment to their company to help recruitment and retention.  All who spoke were well meaning, earnest people who truly believed that what they were doing would be helpful and useful to all concerned.  However it struck me that depending upon their particular lens, they were sometimes speaking different languages and had trouble bridging the gap between their own fields of vision. 

I have spent a good part of my career as a translator between those different worlds.  As a physician consultant for a large international benefits consulting company, I helped traverse the difference between the business world of cost charts, analytics related to claims payments, and the black and white of insurance contracts, with the medical world of pathology, randomized studies, and the shades of grey of actually treating patients.  I often had to deal with physicians who believed that health is everything and costs and contracts are mere distractions, and therefore must be made secondary to the medical issues.  I dealt with business people who truly believed that to be responsible stewards of the health dollars that were available they had to divorce themselves from the tragedy that specific people with specific illnesses had to deal with and make policies and procedures that protected the bulk of the people for whom they were responsible.  As I tried to chart a course that addressed all these issues, I often found my skill as a translator challenged as it seemed like I was bringing a third language to the cacophony of voices. 

This week, all this came to mind as I sat down with a group of journalists while at the meeting to discuss what we at Accolade were doing and how that was saving money and helping people.  At Accolade, we founded the company with neither that primary financial or medical lens, but rather the real world challenges of a person trying to find their way to the best care possible for themselves and their families.  As we built the company, we realized that our system of each family having their own health assistant could potentially help the problem as long as the health assistant had a laser focus on neither the medical nor the financial alone but rather on the person and family’s needs and wants.  When you focus on a person, you must know and address the financial and the medical but it always must be from their point of view, knowing their priorities and the real life barriers they need to overcome.  We developed our system and the curriculum for our Accolade Health Assistants and made sure as we built all of our training and supervisory programs that we never had saving money or directing medical care as primary goals for our health assistants.  Instead, we set primary goals of gaining trust, forming relationships and assisting those in need get the care they need in the context of the real world in which each and every one of them live.  We believed that by doing so we would end up saving money.  That belief, eight years later, has proven true.

I described this to the journalists who looked askance and could not understand why our health assistants did not have a primary goal of saving money, as they believed that focus would be more effective.  They did not totally understand our desire not to be directive in telling people what they should do.  They spoke a different language than the one I was speaking when I talked of the focus on trust and the paradox inherent in lowering costs and improving care based on building trust. A key component of trust is that there must be no hidden agendas.  A hidden agenda of saving cost for your employer could potentially destroy a relationship before it is even started.  This would lead to lower savings.  Another key component of trust is mutual respect.  Telling someone that they are wrong, or their doctor is wrong, about what should be done also destroys trust.  This could lead to worse quality of care.

As a translator, I use the power of language to achieve the goals of lower costs, higher quality and higher access to needed care.  The concept of paradox is thus useful.  The definition of a paradox is a statement that apparently contradicts itself and yet might be true.  In our work on health care cost, access and quality, we have learned a number of paradoxes that have proved true. 

• When you focus only on money in health care, costs go up
• When you focus only on the scientific tenets of medicine, and not the financial, emotional, cultural, spiritual and social aspects of care, quality goes down
• When you focus only on the population rather than the individual, the population suffers

Thus a singular focus on the medical or the financial, or even on a specific disease, while helpful analytically is also limiting and must be met by a healthy dose of understanding of the overall goal of helping an individual and their family achieve the overall well-being that is desired.  Only then will we achieve the lower costs, higher quality of care, and better access results we all want.  

Questions, Caring and Competence

A good friend and a leader in medicine, Dr. Saul Wiener once said to me that “questions are caring.”  In the case of patient care, the asking of questions, often questions that are never asked in polite company, is not only a way of gaining information to make a diagnosis, but a way to indicate a true interest in the person who sits before you seeking help.

It used to be that the only time these types of personal questions would be used was in the sanctity of the exam room when they were combined with the physical exam.  These questions must, to some extent be intrusive to truly get at the heart of a person and of an illness.  They must mirror the physical exam as described by Dr. Abraham Verghese in an article he wrote in 2009 when he stated;

“The physical exam is really about one individual granting permission to another individual to touch his or her unclothed body, to probe the most ticklish and private places.  The exam then is about trust, about a sacred privilege.”

However, in today’s digital world, when the exam may be over the phone, via email, or via video chat of some type, the trust and sacred privilege is often built independently of that “granting permission to touch.”  Questions posed to patients must sometimes take the primary role instead of the integrated role that they did historically as part of the “history and physical” that first year medical students learn.  Personal questions, in many ways, are also about touching the most “ticklish and private parts” in a different but perhaps more difficult way.  In today’s world, the types of professional who must develop the trust and invoke the sacred privilege also goes beyond the physician and nurse of old and must include physician assistants, therapists, and even the new professionals such as the health assistants that I work with every day at Accolade.

We ignore, or minimize the asking of questions and the human “touch” that those questions reflect in our highly technical world at our own peril.  In every human endeavor questions are often more important than answers.  A famous story is told of Isidor I. Rabi, the 1944 Nobel Prize winner in physics who was once asked, “Why did you become a scientist, rather than a doctor or lawyer, like the other kids in your neighborhood?” “My mother made me a scientist.  Every other Jewish mother in Brooklyn would ask her child after school: ‘So? Did you learn anything today?’ Not my mother.  She always asked a different question. ‘Izzy’ she would say, ‘did you ask a good question today?’ That difference made me a scientist.” 

Questions are not limited to those asked to patients in order to make a diagnosis and form a trust bond with patients.  Questions asked to colleagues are equally important in helping those in need.  Medicine has always been collaborative, however informal the collaboration of old was.  The best care for the patient was the product of continuous ongoing discussion between doctors, nurses, therapists and social workers.    

We seem to be at risk of losing the power of iterative questions as medicine becomes more dependent on technology, apps and computers.  I speak of both the questions that health professionals ask patients, and the questions that health professionals ask each other.

This issue of whether technological advancements in medicine may negatively impact that ability to ask personal, interactive questions of patients, and to foster questions between professionals was reflected in a discussion by Dr. Robert Wachter, Associate Chairman of the Department of Medicine at the University of California at San Francisco, and Dr. Atul Gawande, from the Massachusetts General Hospital in the on-line magazine“Quartz.” 

Dr. Gawande starts the discussion by talking about innovation in medicine by stating that “In all of the cases, the most fundamental, most valuable, most critical innovations have nothing to do with technology.  They have to do with asking some very simple, very basic questions that we never ask.  Asking people who are near the end of life what their goals are.”  He starts with the supposition that it is the questions that are important, to drive innovation rather than the technology.  This is interesting as it is in stark contrast to the point of view put forth by Vinod Khosla, the highly successful technology entrepreneur who has stated that 80% of what doctors do should be replaced by machines, and that we are headed towards an “evolution from an entirely human-based healthcare system to an increasingly automated system.” 

Dr. Wachter, later in the conversation makes the observation that residents – the doctors in training – are often struggling to connect both with patients and with their colleagues.  Dr. Wachter states, “But it’s hard – the residents feel they’re caught up in this world where everything they need to know is on the computer screen.  That’s creating angst in their day-to-day lives.  You go up to the floor of the medical service in my hospital and there are no doctors there.  They come, they see the patients, and then they escape to this tribal room where all 15 residents hang out together, each doing his or her computer work.  That means that many of the informal interactions that used to occur between docs and nurses, or docs and patients and their families, have withered away.  Dr. Gawande replies to that with “Everything that they’re measured on and that defines their success happens outside the patient’s room.”  “Getting through the to-do list is the dominant task.”  Abraham Verghese says something similar when he states, “An anthropologist walking through our hospitals in America wouldn't be blamed for concluding (on the basis of where physician spend the most time) that the real patient is in the computer, while the individual in the bed is a mere placeholder for the real patient.” 

We must, as a society and as health professionals, get back to emphasizing the human touch, whether it is in the form of an actual touch, or touching someone by asking questions, by showing interest in who they are and not only in what disease they have. 

The question I ask is whether we can focus on using technology to build systems that foster communication and questions.  Can we take the information collaboration of the past that unfortunately appears to have become technology driven isolation, and facilitate a new platform of collaboration between the direct caregivers, other professionals and patients, built on supporting the sacred trust that should be inherent in healthcare.  We must emphasize that even in our new technology driven medicine, touching someone through questions and questioning our colleagues is not only necessary for caring, but also defines basic competence.