Healthcare, Humanism and the Humanities

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.  

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.   

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."

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 “How I Spent My Summer Vacation and the French Paradox”). 

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. 

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. 

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.

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.  

The Balancing Act of Health Care

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. 

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. 

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. 

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:

1. How do we fit the black and white of contracts, legislation and regulations into the shades of gray that good medical care requires?
2. 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). 
3. 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? 
4. 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?
5. 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. 
6. 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? 
7. 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?
8. How do we encourage good health habits while not creating a system that punishes those who do not follow those habits? 
9. How do we prevent care equity becoming poor quality, least common denominator care for all?
10. How do we acknowledge health care as a spiritual and social need and not only a biological one?  

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.

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.  

Moving On

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. 

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. 

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!” 

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. 

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.  

What Does the Patient/Consumer/Beneficiary/Person (pick your word) Care about when Accessing Care?

A new survey commissioned by Accolade (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. 

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 only 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.”

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. 

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. 

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. 

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.

 

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.  

The Place of Passion in the Business of Health Care

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.   

  

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.

 

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. 

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. 

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 an article published in the Annual Review of Psychology, 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, “Feeling Smart,” Eyal Winter cites a study that shows when we are moderately angry our ability to distinguish between relevant and irrelevant claims in disputed issues is sharpened. 

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. 

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. 

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. 

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.

The Cost of Care When Nothing is Wrong

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.  It ignores the much larger number of patients, with the larger percentage of unnecessary care, representing the bulk of those who seek care.

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 words of Francis Peabody 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 cost of care by Saul Weiner and Alan Schwartz. 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.  

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.  

A recent review in the Harvard Review of Psychiatry provocatively entitled, “Medically Unexplained Symptoms: Barriers to Effective Treatment When Nothing Is the Matter” By Lipsitt, Joseph, Meyer and Notman 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.”  

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.  

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.    

Physicians on the Assembly Line

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.   In an article this week in the New York Times, 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. 

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?

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.”

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. 

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.  

“Strangers at the Bedside” and the Internet Economy

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. 

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 “Strangers at the Bedside” 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. 

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.

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 “The Lexus and the Olive Tree” 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. 

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, “The Healer’s Calling.”

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, “In Silicon Valley Now, It’s Almost Always Winner Takes All” 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.” 

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. 

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?

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. 

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. 

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.