The Economic Need for Improving Patient Decision Making

As the New York Times says, “It’s back.” Healthcare spending, which had moderated for the past few years, is beginning to rise once again.  The rise in healthcare spending is being driven by more visits to doctors’ offices, more hospitalizations, and more prescription medication use.

Healthcare spending can be thought of as having two components: a unit cost component (such as the cost of an office visit or a day in the hospital) and the volume of services (such as the number of office visits or days in the hospital). The volume of services is driven by the number of people using healthcare services and by the number of services each person receives. If it is successful, the Affordable Care Act, will increase the volume of services by increasing the number of people with better access to the healthcare system.  That will drive a national increase in healthcare spending. There is, however, an opportunity to impact the volume of services by decreasing the number of unnecessary services each individual receives. In studies that were initially done by the RAND Corporation – and have been replicated over and over – researchers found that as much as one-third of medical costs are unnecessary.

Each individual service in healthcare is driven by doctors’ and patients’ decisions. While many see medical decision-making as being a physician endeavor, the truth is that patients make many more decisions than doctors. Think about all the decisions made in relation to health and healthcare:

Who Makes the Decisions?
	Doctor	Patient
Staying Healthy	NO	YES
Deciding to Seek Medical Help	NO	YES
Diagnosing	YES	YES
Treating an Illness	YES	YES
Complying with Therapy	NO	YES

Many of the projects and demonstrations that are part of the Affordable Care Act are focused on physician decision-making. However, influencing patient decision-making can have a profound positive effect, in terms of better quality care and lower costs. When you gain people’s trust, respect their values and beliefs, and help them to come to better decisions, the result is lower costs -- often dramatically lower costs --, and better care. In addition, patients end up being happier with their care experience, which in today’s world is otherwise an experience filled with fear and confusion.

How is this done? There is not one answer -- and I would not be so arrogant as to suggest that there is. When you look at the innovations (including our own efforts at Accolade) in the area, they have certain commonalities. I would divide them into the following categories:

• Building patient – professional trust early
• Understanding and accounting for the dynamic nature of illness, rather than approaching it as a unique disease at a single point in time
• Understanding the isolating nature of illness and the power of having a trusted professional at the ill person’s side
• Taking people’s beliefs and values into account and affording them the respect they deserve
• Understanding the social, psychological, economic and spiritual nature of illness
• Giving health professionals the time, systems and training to truly engage with patients and families and not only to treat the disease pathology

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So while the Affordable Care Act will, we hope, give more people access to insurance and may increase the volume of services, we at Accolade are dedicated to making sure that each individual we help makes decisions that are the most likely to be necessary and helpful. In that way, we can minimize unnecessary services and lower the total cost of care in the process. 

Trust, Money and the Physician’s Role

Should a discussion of healthcare costs ever enter the exam room? Should doctors be rewarded for focusing more on costs when seeing patients?   A recent viewpoint article in the Journal of the American Medical Association (JAMA) entitled “Health Reform and Physician-Led Accountable Care” suggests that primary care physician-led accountable care -- with proper incentives for physicians to focus on lowering unnecessary costs -- may be the answer to the healthcare cost dilemma. I read this article and shared many of my fellow bloggers’ opinions: This is a wonderful advance in our national discussion -- and yet, in other ways, I was also frightened by some of the implications. I cringe somewhat when I think of physicians being responsible for the costs of the care they are recommending for me as a patient. I worry that the imperative to lower costs, and the financial incentive to do so, will subvert the focus that a physician should have on the patient’s well-being – and, in so doing harm the sacred trust that should define the physician- patient relationship.

The authors start out by saying: “Even though most adult primary care physicians may not realize it, they each can be seen as a chief executive officer (CEO) in charge of approximately $10 million of annual revenue.” That alone was enough to scare me. When I walk in to a doctor’s office, I want that doctor to be concerned about my life, my problems, my symptoms, and my concerns --not the running of a 10–million-dollar-a-year business. I want my abdominal pain, my chest pain or my fear of dying to be foremost in his or her mind, and not the desire for a return on investment. I do want my physicians to think of cost when it is important to me, as the patient. If I, for one second, believe that their commitment to help me is being influenced by some other concern, the trust that I must have in them – the trust I need for the therapeutic relationship to work -- is undermined.

And I am not alone. In that same JAMA article, the authors noted that “Physicians see opportunities every day to improve quality and lower costs, but in a recent survey reported that they should not be expected to play a central role in controlling costs.” I understand that attitude. Doctors are in the business of managing the uncertainty of illness, and if they are to work with patients to manage that uncertainty, the patient must trust that physicians’ total focus imperative is on helping them, not on the costs to the system.

Patients feel the same way. In a February 2013 Health Affairs article, researchers from the Rand Corporation ran focus groups asking if cost should enter into medical assessment and treatment. That article, “Focus Groups Highlight That Many Patients Object to Clinicians’ Focusing on Costs,” found that “the majority of participants were unwilling to consider costs when deciding between nearly comparable options and generally resisted the less expensive, marginally inferior option.” The authors identified a number of “barriers” for this unwillingness to discuss costs -- and all of them were related to the need to trust that their physician will do what is best for them, in the context of their lives. From a patient’s point of view, putting their doctor at financial risk to save money can undermine that necessary trust.  Patients want physicians to spend time with them and they fear that an emphasis on cost and efficiency will limit that time. 

At Accolade, we have developed a system that involves health assistants -- who are evaluated and rewarded almost solely on their ability to understand the people in need, and to help them fulfill their needs in the context of their life and their values. The true paradox is that when you focus on what people want and need, and take the time to build trust and address those wants and needs, you save money. As that trust forms, health assistants can help people manage the uncertainty of illness and help educate them to the fact that sometimes higher quality means lower costs.

Physicians know how to save money by making care safer and more personal, but most of the systems that attempt to incent primary care physicians to achieve savings, and make them the “CEO” of the healthcare dollar, have the unintended consequence of potentially eroding trust. Physicians are dedicated, smart, focused individuals who take on a priestly, sacred responsibility for their patients. Anything that may erode that trust is unlikely to improve care, save money and achieve our societal goals. 

Unnecessary Care, the 80/20 Rule and the Nuka System of Care

Last week, I wrote about the need to turn our current care management paradigm as it is related to the patient centered medical home on its head. I argued that we should focus more on those who don’t need intensive medical care, per se, but need help in other ways -- and who access the medical system because they don’t know where else to turn. That paradigm is based on the much touted“80/20 rule,” which holds that since 80 percent of costs are driven by the sickest 20 percent of people, cost-control efforts should focus on the 20 percent, as that will be more efficient and potentially more effective.

It pays (pun intended) to first review the 80/20 rule. The shortcoming of this rule is that it focuses on total costs and not on the subset of unnecessary costs. From my years in practice, and my years in medical economics and health policy, I know that the people who drive the highest percentage of unnecessary costs are in the 80 percent of patients who drive 20 percent of overall costs; the high-cost 20 percent are not, in most cases, incurring unnecessary costs.

Comparing two patients may help illustrate this. Consider the type of person I saw often in my gastroenterology practice. A person who is “health-anxious,” who is stressed at work, and who has perpetual stomachaches and constipation will often go to multiple doctors during the course of the year, have many tests and be on many medications, and may have pain severe enough to go to emergency rooms; at the end of a year, that person may easily cost the system $25,000 or more. Another person – this one with end-stage liver disease -- maybe in and out of the hospital with mental status changes, abdominal fluid and GI tract bleeding, until he or she undergoes a liver transplant; that person may cost the system $250,000 or more.

On whom should we focus? The one who costs $25,000 or the one who costs $250,000? When you actually look at both sets of medical records for signs of avoidable costs and waste in the system, you usually find that the lower-cost person --who is seeking care because of psychological and social issues as much as medical pathology --undergoes a higher percentage of unnecessary care than the high-cost person who is receiving needed high-intensity-of-service care. In aggregate, thankfully, there are many more patients with nonspecific abdominal pain and constipation than those in need of liver transplants, so the potential aggregate savings among the 80 percent is quite significant. The real answer however is to help both.  Help the bulk of patients who need reassurance, social and psychological support even more than they need diagnostic evaluations and help the smaller number of people who need excellent, well-coordinated care due to the severity and complexity of their diseases.

If the goal is to influence people toward better and less wasteful care -- while addressing their needs in the context of their values --it makes more sense to focus not just on the high-cost people, but also on those who are lower-acuity and often not suffering from diagnosable, treatable medical illness. Yes, we must help those with severe illnesses access the system in timely ways, get to the right physicians and facilities, and receive the right care without putting roadblocks in their way, as their care coordination needs are great. But even care for high-cost patients requires us to acknowledge that healthcare is not only about biology, but also about the psychological and social dynamics that are part of being human.

Two recent articles – one published in the International Journal of Circumpolar Health and the other in the Annalsof Family Medicine -- describe the Nuka System of Care in Alaska and give voice to the idea that focusing on people who are relatively healthy– the 80% and not only the 20% -- may be more productive in trying to decrease healthcare costs in the United States. In the International Journal of Circumpolar Health, Katherine Gottlieb states: “Southcentral Foundation’s Nuka System of Care is based on what customer-owners really want – a primary focus on building and maintaining relationships.”

Based in Anchorage, Alaska, the Southcentral Foundation Nuka System of Care is a customer-driven healthcare system that has arisen out of the bureaucratic morass previously centrally controlled by the Indian Health Service. Alaska Native people are the “customer-owners” of this system, and they have developed care based on physical, mental, emotional and spiritual wellness and dedicated to a team approach based on relationships rather than on regulation. It is most telling to review their concept of who controls healthcare, as this has driven much of their processes to improve care while decreasing costs. In the Nuka System of care, low acuity care is seen to be driven by patient and family decisions while very high acuity care is seen to be driven by the decisions that physicians and other health professionals make.  In other words, 80% of the people who access health care and use the health care system are making their own decisions with their families and friends while only the sickest people are under the control of medical decision making.  Acknowledging that patients and families make the bulk of healthcare decisions, especially when disease acuity is relatively low, is an important first step in understanding how best to decrease unnecessary care and thereby lower costs. 

Quoting the Alaska Health Policy Review in 2009 from their discussion of the Nuka System of Care;

“The current model that drives healthcare is very linear and assumes that the system and the experts in the system are the source of expertise and therefore the power and the structures are centered around them and their concepts. In medical processes the medical professional collects history, symptoms, and signs and comes up with a differential diagnosis. Then a lot of tests are ordered. The interpretation of these leads to a definitive diagnosis which leads to the prescribing of pills and procedures based upon protocols, standards, and best practices. Then they think they are finished.   

The reality is that the decisions that really determine illness creation and chronic condition optimization are mostly under the control of the individual – whether to pick up the pills, to take them as prescribed, to share them, to split them, to quit taking them, to use the oxygen as directed, to use the technology they are given, what they eat, how they sleep, whether they exercise, whether they smoke, whether they drink too much, how they handle frustrations and anger, etc.  …these are all under their control. These decisions are also hugely influenced by values, culture, religion, family, friends, internet, work, hairdresser, bartender, etc. We are foolish to think our short visits and medical paradigms will drive everything. This is a failed model.”   

                            

Gottlieb reports that the Nuka System of Care has seen a 36 percent reduction in hospital days, a 42 percent reduction in emergency room and urgent care usage and a 58 percent reduction in specialty clinic use, while seeing an increase in customer satisfaction and a 25 percent increase in childhood immunizations. The Annals of Family Medicine reported improved access to care and decreased emergency room use, for all causes -- including for asthma, which was evaluated in more depth.  The bottom line? Relationships and a focus on all people -- whether their sickness is medical, social or psychological -- works to improve care and lower costs.

Yet the “failed model” – the one that focuses only on illness and also focuses on the sickest people -- is a model that the managed care industry and health plans have perpetuated with the rules, regulations and medical policies that are in place to “manage” medical care, especially the medical care of the small number of extremely ill people.

The work we do at Accolade, attempting to build trust with people early and when they are low-acuity, is the best way to fix the system, just as the people at the Southcentral Foundation’s Nuka System of Care in Alaska are doing. Both models understand that building relationships based on trust leads to significantly lower costs -- while maintaining the sacred role of care in our society and that approach is our best hope to decrease costs in a humanistic way in the United States. An 80/20 approach of trying to micromanage the sickest people will never be able to achieve as much.

What is Patient-Centered? – Ask a Patient!

A recent article and an accompanying editorial in the Journal of the American Medical Association reveal much of what I believe is both right -- and wrong --- about the direction of medical policy and medical care in these United States.

The article noted reveals that the patient centered medical home, which is the team-based approach of primary care in which primary care practices are paid more to coordinate patient care, does not produce savings or perhaps even significant improvement in the quality of care as was expected.  The editorial implores readers to carefully consider the results and avoid the conclusion that the patient centered medical home is not effective.  The author of the editorial then argues that the patient centered medical home, in order to be more effective, must better identify the really sick people and focus more on them.

I agree with the editorial that there is still promise in the patient centered medical home and that we must find ways to improve the function of that wonderful concept.  I am, however, troubled by the thought that focusing on sicker people, as the editorial suggests, through the patient centered medical home will lead us to the promised land of lower costs and higher quality. It seems like this arguments, and indeed the very structure of the medical homes as implemented, still tend to see people as the sum of their medical risks and illnesses rather than the person who has a life, and who may or may not have an illness. The patient centered medical home, by being focused on a physician’s office, rather than the patient’s home, may be missing the opportunity to try and enter in to a person’s life, even before they feel the need to see a doctor.  I wonder if we have to turn our current paradigm on its head, and focus on those who are not severely sick. To me, it makes more sense that people who are not suffering from diagnosable, treatable medical illness are the ones on which we should focus -- to try to help them avoid getting caught in the medical system that seems to respond to every unhappiness with a blood test, an imaging exam and a prescription.  What I learned while in practice was that most patients who seek medical care do so because:

1. They feel isolated and alone with their discomfort.
2. They are afraid.
3. They are hurting both physically and emotionally; however, the psychic pain is sometimes worse than the physical.

Some of these people have medical illnesses -- from upper respiratory infections to advanced cancer -- but they still come to the doctor for peace of mind and hope as much as they come for cure. When I was in practice in gastroenterology, I saw many, many people with abdominal pain, constipation, nausea and other symptoms. I sent many of them through evaluations that included imaging, endoscopy, and blood tests, even though I suspected that the best way to help them was to watch and wait. I knew, however that their fear and their perceptions of pain were such that watching and waiting would, in their mind, be tantamount to “doing nothing.” Usually the tests were unrevealing; however, they were also often reassured by the tests as that, in their minds, was “doing something.”  I thought that they benefited most by having someone to talk to about their symptoms and their life, but by the time they came to see me, especially as a specialist, they often could not hear me unless I “did something.” Testing became a way to share their concern and to help them feel listened to and less alone. The mindset by the time a person walks into the doctor’s office is that he or she wants a medical intervention, a medical test, a medical therapy -- whether or not the issue is medical, social, financial, cultural or behavioral, because in their mind, it is medical.

To find a way to decrease the over-testing and the overtreatment that is harmful and wasteful, we need to find people before they take that fateful step to visit the doctor. We need to enter their homes and their lives and help them realize that medical science cannot solve all of their problems. In my days in practice, I managed people on home nutritional support.  I found that when I went to people’s homes, I was able to better see into their life and understand how to help them without necessarily running a blood test.  In my current role, as I speak to people on the phone, I am struck by how often even on the phone, when people are in their homes, they are able to open up and talk about topics that in the sterile environment of the doctor’s office are impossible to discuss. 

In order to really foster patient/person-centered care, which should theoretically increase needed care and decrease unnecessary care, we have to ask two questions. They are:

1. Do people want a medical home, and if they do, what do people want from a medical home?
2. Why do people, who presumably do not like to be poked and prodded, do not like to spend money they do not have, and do not like to waste their time, receive -- and often seek out -- unnecessary care?

The answers may be so obvious that we are missing them. Here at Accolade, in our early years, we decided to ask people questions like this, in surveys and in focus groups. We asked what people wanted and needed as they accessed health care and health benefits. We learned people wanted a friend to stand by them. They wanted help through a difficult system, provided by someone they trusted. They wanted the proverbial place where everyone knows their name, even if it was virtual, over a telephone. They wanted a human being who knew them and their family and who understood what their values and concerns were. They really don’t necessarily want to be over-tested, but they wanted assurance that everything possible will be done if they are really sick -- and that the zeal to lower costs wouldn’t leave them sick and even at risk for death.

How to do this? At Accolade we do it with the Accolade Health Assistant®, who, for 60+% of the population we serve, will form a relationship with someone before he or she goes to the doctor. Community outreach programs with community health workers have the potential to help. Sometimes efforts as simple as community social centers with proper staffing can create atmospheres in which people helping people they know, takes the place of that unnecessary and often misguided trip to the doctor. Perhaps telemedicine systems allowing people the safety of talking to the doctor or nurse while they are in their own home.  I don’t expect there to be one answer that is right for everyone, but I do expect that the answer will be based on the power of human connections, more than on a medical model of disease intervention.

In many ways, the challenge to the patient centered medical home is that we really need person- centered holistic homes instead. We need safe places where people in need of support, hope, friendship, and help can turn to when they are in need.-- places to receive the kind of pointed advice and information that they need in order to avoid the risks and costs of being tested, prodded and poked unnecessarily at great expense to themselves and to society in general. 

Food, Relationships and Health: A Family History

As a Jewish-American, I am part of a culture in which food plays an integral role. In my family, however, it seems to go beyond the shared Jewish cultural history. A few years ago, I had the chance to stand on a hill in southern Poland, about two hours from Krakow, the closest major city, on the spot where my father lived as a child, and -- with his family -- ran a small restaurant and inn, providing shelter and food to the surrounding community. The Holocaust ended that endeavor. My father had, thankfully, moved along before then (tragically, not most of his brothers and sisters), but the family history stayed with him. In the United States, he, too, pursued the family food business, owning a small food store in New York City throughout his adult working life. I grew up bagging groceries and watching my father talk to the people in the store, understanding that his personal relationship with those people was as important as the food they were buying. When the larger supermarkets started popping up, my father would jokingly say that his pricing strategy was “nobody oversells me” -- meaning his prices were higher than larger stores. He knew he could not compete with a large chain that had buying power. But my father had the back of his envelope, on which he kept track of the interest-free credit he gave to people who needed food --a symbol of the personal relationships he had with his customers.

I watched and learned – and I continued the family tradition of interest in and support of food, except from a medical point of view. I ended up first in gastroenterology and then as a research fellow in nutrition, eventually becoming Board-certified in nutrition.  But I also continued another part of the family tradition – a belief that personal relationships were another form of nutrition. Nutrition for the soul, perhaps, but no less important than the food one puts into one’s mouth. I came to believe, both from watching my father -- and also from watching my mother prepare traditional food with love (from gefilte fish to pierogies) that food was part of the personal relationships that truly make life worth living.  I knew, from the way my mother invited total strangers into our home for dinner when there was a holiday or an occasion of any type, that there was a lot more to eating than the fuel the body needed, and that, in life, one should nourish others in many different ways.

My family history also led me to remain focused on the relationships I had with my individual patients. It further led to my career developing health strategies and managed care systems that were focused on individual relationships and individual needs, when I perceived around me a depersonalization of care systems.  When we started Accolade, it was out of this belief -- shared by all involved --that forming relationships with people, providing them with the nourishment of a friend and a helper when they were in need, was the right way to try and save our healthcare system. We have been proved correct, and with each person we help, I think about my father and my mother and what they taught me.

While my own career over time veered toward healthcare relationships and became less focused on food, my son, Rob Spiro, continued the family tradition of feeding others. He started a company Good Eggs which is also built on food and relationships. It fosters the nutrition and the personal, even emotional, aspect of good food being produced by people who care, and delivered (both literally and figuratively) to people who need that food. When he started the company, he called me and said, “Dad, I’m a grocer!” He has now taken his company to the point at which it is starting to change the paradigm of food production and distribution in ways my father, and his parents in rural Poland, would never have imagined. As I watched this video about Good Eggs, I could not help but see the unbroken link from my father’s family in Poland, to my father, to me and now to my son as we all try to feed the body and the soul. 

Mutual Respect and Trust

This interesting opinion piece from a pediatrician – Dr.Russell Saunders –expresses frustration with parents who don’t want their children vaccinated and I share that frustration. However, I also admit to having mixed feelings. I sympathize with Dr. Saunders, but I also feel a bit upset with him for falling into the trap that my good friend, Dr. Saul Weiner at the University of Illinois, describes as the “I-it” relationship trap. The “I” in the trap is the doctor who can easily see the patient as the “it” that should merely do as it is told. It often is easier and more efficient to just tell a person what the medical evidence suggests they do and move on to the next person, however the real job of a physician is much more difficult and nuanced. It is to be with patients and guide them through the uncertainty and discomfort that is illness by first recognizing what makes them unique as a person and giving them respect and trust and then applying scientific medicine.  Unfortunately, many physicians only focus on the respect they are due as the doctor -- and not on the respect they must give their patients -- and that impairs their ability to form a therapeutic relationship. In a sense, Dr. Saunders’ reasoning is evidence that medicine continues to cling to the belief that human beings are rational – that by presenting them with the facts, we can convince them. Behavioral economics teaches us otherwise.

Dr. Saunders says he is not looking to return to the paternalism that used to characterize medical care. However, we risk a new type of paternalism – one that places absolute faith in the medical scientist – a belief that the only way to proceed is the way the peer-reviewed medical journals and the expert committees declare to be correct. Dr. Saunders writes:

The physician-patient relationship, like so many other human relationships, requires an element of trust. I certainly neither want nor expect a return to the paternalistic “doctor knows best” mindset of bygone years, but I do need to know that patient’s parents respect my training and expertise. Refusing an intervention I desperately want all children to receive makes that respect untenably dubious.
There will be times when parents and I may not see eye to eye, but not where I’m using the best evidence at hand to support my recommendations. Maybe they’ll want a test I think is useless, or want to use a supplement shown to be harmful. Perhaps it will be a referral for an intervention shown to have no benefit. If I can’t hope to persuade them by making reference to the available research, what can I expect to be for them other than a rubber stamp for their ideas? If medical science can’t answer the meritless qualms they have about vaccines, when can I use it at all?

I read this and can’t help but believe that the author does not really believe everything he writes. for he seems to be a caring physician. I am sure he knows that respect for the parent would warrant a discussion of why parents feel and believe the way they do. That discussion would require an understanding of their values, their culture and their beliefs, rather than simply pointing to the “available research” as the right way. The approach he writes about implies that if you can’t understand the importance of the science, you are bad parents and not worthy of my help.

His opinion piece also lacks the humility that should be inherent in any mutual trust relationship, especially one that goes beyond a friendship and is a true calling, as medicine should be. Medical facts change; new research brings new insights every day. Nothing is “settled,” and everything changes, even vaccinations; new vaccine formulations are constantly being developed. The Salk vaccine for polio was a godsend and was the only right answer until the Sabin vaccine was developed.

That does not mean I would agree with parents who refuse vaccination and just say “yes” to their request not to vaccinate their children. I would not. But I would also not reject them out of hand and assume that if they can’t accept the available research, my answer should be to ban them from my practice.

Dr. Saunders’ opinion piece reflects many of the frustration in medicine today -- with one of the root causes related to the incentives put in place by health plans. I cannot help but feel that our approach to health benefits, and our push toward efficiency in medicine, has created a situation in which the building of mutual trust between a doctor and a patient has become almost impossible. Health plans tell doctors which algorithm to follow and reimburse them in ways that encourage shorter office visits, more use of physician extenders, and adherence to protocols -- no matter what the patients’ beliefs and values are. Following those protocols and practicing the way Dr. Saunders writes about -- refusing patients who do not follow “doctor’s orders”--will make the numbers look better for a practice, make it more likely to receive the health plan quality bonuses, and make it more efficient. It may also relieve physicians’ frustration in this modern day system.  But will it truly help those who are most in need? I am not so sure.

I can’t help but think back to my days in practice, when I treated patients who, due to their religious convictions, refused blood transfusions.  As a gastroenterologist treating people who suffered from acute gastrointestinal bleeding, I knew that prohibition against blood transfusions went against every care algorithm and every medical standard. I would always try to convince patients of the need for the transfusion, but always with respect for their beliefs and with the proviso that I would treat and help them no matter what they decided. That respect was critical for mutual trust. What was so very interesting to me was that these patients were treated successfully, and we did not lose patients at a higher rate than other patients who presented with the same problems. Many who initially refused transfusion did accept it as their condition progressed.

That taught me a valuable lesson: Science is necessary for care, and following the most up-to-date recommendations is important, but nowhere near as important as respecting your patient -- and fostering mutual trust in such a way as to be not only a doctor, but a healer. 

Speaking and Hearing

Doctors and nurses often don’t speak English. They speak “medicine.” When I was a young medical student at Columbia University, Dr. Lewis Rowland was the new Chairman of Neurology. Even then, he was already a giant in the field, but he was, at that point, a young giant. In my eyes his greatness was as much a function of his ability to understand the need to communicate clearly as it was his knowledge of and research in neurology. When a medical student would present to Dr. Rowland -- which was always an occasion of great anxiety -- the student’s knowledge of neurology and the diagnosis of neurological diseases would be tested, but so would his or her ability to speak English. The minute a student stated “the patient had upper extremity weakness,” Dr. Rowland would stop the student and say in a questioning tone, “upper extremity?” He would then, with great flair, state, “Oh, you mean arms!” He would never let a student or a resident get away with speaking medicalese when English was available.  

Yet even when a doctor or a nurse makes an attempt to avoid medical jargon and speak English, the fear and emotions that are part of every medical encounter makes hearing what is said extremely difficult. In a recent New York Times blog post entitled “Lost in Clinical Translation,” Theresa Brown -- who is an oncology nurse and an author --talks about the need to pay more attention to both what doctors and nurses say and what patients hear. She starts her post with the following analogy:

A classic “Far Side” cartoon shows a man talking forcefully to his dog. The man says: “Okay, Ginger! I’ve had it! You stay out of the garbage!” But the dog hears only: “Blah blah Ginger blah blah blah blah blah blah blah blah Ginger …”

As a nurse, I often worry that patients’ comprehension of doctors and nurses is equally limited — except what the patient hears from us is: “Blah blah blah Heart Attack blah blah blah Cancer.”

Her choice of the word “translation” in her title is especially meaningful for me. I have often said that in medical school I did not learn how to practice medicine; I only learned the language of medicine. As someone with a great love of the English language, I was struck at how different the way medical professionals communicate is from the way the rest of the world communicates. The intent is often good, and that is to be precise when plain English may not be precise enough.  That is not only limited to the medical world. It seems within every discipline and within every culture, there is a language all its own. When I decided to go back to school to study business and work toward an MBA degree, it was because I was already involved in discussions having to do with healthcare costs and management systems, and I was frustrated because I did not know the language. I felt I needed the formal coursework to learn to translate from medical to business.

In our society, when we speak of healthcare, if we are speaking from a point of view of legislation, the language is government. When we speak from a point of view of costs, the language is economics. When we speak from a point of view of technology, it is “techno-speak.” And so we speak multiple languages, even when we think we are all speaking about the same thing: healthcare. For me, that is all just noise, as the real language of healthcare is the conversation that occurs between a person in need and a health professional, even if that professional is a professional office worker in a doctor’s office. That, for me, is what being patient-centered is really all about.

But whatever the language, and no matter how well it is translated, it’s also important to remember that what is said may not be heard. Ms. Brown’s blog article points out that challenge. She described a situation early in her nursing education when a patient who was in the hospital for a pulmonary embolism (medical speak for a blood clot that travels to the lungs and damages part of the lung, making it difficult to breath) is seen by the medical team who explain her condition to her. She writes:

“To me, just at the start of my nursing education, the explanations were clear and easy to follow, and I felt hopeful they would give my patient some comfort.

After the rounding team left, though, she turned a stricken face to me and deadpanned, ’Well, that was clear as mud, wasn’t it?’”

Taking time to communicate clearly – and even more importantly, to ensure that the communication is heard and interpreted in the way it was intended – is part of the art of medicine, whether that art is practiced by a doctor, a nurse, a therapist, or even a clerk at the front desk. I fear we will not focus enough on this communication as we move toward efficiency as the goal of a cost-conscious health system.  Without taking that time, and leaving the understanding between the medical professional and the patient wanting, the efficiency that results is a false efficiency – and costs will actually go up.

As we, as a country, struggle with medical costs, we should start by recognizing that by paying for more medical personnel who slow down and speak in plain English – to make sure that patients are hearing what was said – will save more money than we will through technology and efficient networks.

It also supports the model we have developed at Accolade. At Accolade, our clients have their own Accolade Health Assistant® who is skilled at purposeful, understandable communication and relationship-building in order to foster the type of two-way communication that is critical to good, truly efficient care. The clients also often have a Clinical Health Assistant, a nurse, who works with the Health Assistant to offer the medical knowledge (and translation) that is also critical to good, efficient care. With that team approach, the resources for proper, care and two-way communications are in place. The result is better care and lower costs.

The lesson learned for health care more broadly from our experience is the lesson of communication and trust as modalities every bit as important, and perhaps even more important, than the pure science that is integral to good medicine.