Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way – Part 2: The Doctor Patient Dance

Costs are generated when a patient, meets a health professional, (usually a doctor but in our modern world, increasingly a nurse-clinician, a physician assistant or a non-MD therapist), and decisions are made which generate claims and bills and ultimately costs.  An old saying in medical management is that the most expensive medical instrument is the pen, because doctors write orders with pens.  While today it may be the keyboard instead of the pen, the saying is still true.   This may appear obvious on its face however when we think and write of health policies driving either savings or increased costs, we must think about what happens between the patient and the doctor.  This joint decision making may be thought of as an intricate dance that if performed well, results in a sacred trust relationship.  I fear that this dance that doctors and patients take part in is changing and not necessarily for the better.

I have a wonderful primary care physician, who is very smart, and very caring and who was taught to be more attuned to the population trends than I was taught to be, even though I have spent the last thirty years of my life focused on just those population needs.  Needless to say he is significantly younger than I am.  More than a week ago, I fell ill.  I am fortunate because I have medical knowledge, and I am married to the smartest physician I know.  The first few days of the illness, I treated myself, with my wife’s advice.  After five days, my wife convinced me to call my PCP with an eye towards getting an exam and some blood tests because we were both  starting to get worried.  I called my physician and he quite rightly told me that I most likely had something that would get better on its own, and that the best action at that time was  to wait.  On that basis, he said, I probably did not need to be seen and did not need blood tests.  Because we have a close relationship, I kept in touch by phone and a few days later he saw me in his office as I was still sick.  On exam he noted abnormal physical findings and blood tests were found to be abnormal. We both saw that while waiting had not hurt me, it was perhaps not the best approach in this instance as it delayed treatment.  It was, however the right way to proceed from a statistical evidence based,  population health point of view.   I have to wonder if someone who did not have as trusting a relationship with his or her doctor, would have stayed in as close touch with the doctor as I did.  If not, they likely would have ended up with a more serious and more costly medical condition.

The fact is, that even with my sophistication or perhaps because of it, I needed that trusted, objective and knowledgable confidant.  I needed my doctor to examine me and really hear my symptoms and my fears.  I was scared and thinking the worst.  No matter what, I felt better that I was being cared for once I saw my doctor and was able to directly see his concern for me and his thoughtfulness about my problem.  He has a concierge type of practice, together with three other physicians (although they all function as solo practitioners with their own nurse) and their practice fits into what is today considered to be a small medical practice. 

In a study just published on line in Health Affairs, Lawrence Casalino and his associates at Cornell Medical College found that, while it is assumed that large practices, often with team based medical homes and quality of care controls in place,  provide better care, smaller practices of fewer than 9 physicians, had 27% fewer preventable hospital admissions with practices of 1 to 3 physicians having 33% fewer preventable admissions.  Physician owned practices also had fewer preventable hospital admissions.  The authors postulated that this was perhaps due to easier access to the doctor who was part of smaller practices.  My theory is that smaller, more personalized medical practices create more trust.  When your doctor tells you to wait, you tend to trust your doctor and wait rather than run to the Emergency Room and end up admitted unnecessarily.  While waiting, a person cared for in a smaller practice will tend to stay in closer touch, knowing that a call will allow one to speak to your trusted doctor or nurse rather than be triaged by the nurse or doctor on call. 

In our impatient society, one of the hidden secrets of medicine is how time-based it is.  Illnesses tend to follow, what is often called in medicine, a natural history, and throughout much of the history of medicine, the role of the physician was to know the natural history in order to predict, for the patient and the family, what was likely to happen as the physician’s ability to impact what was going to happen was limited.  In our medically sophisticated world in which there appears to be a drug and a procedure and a surgery for every ache and pain, that physician’s art of prediction – of knowing the natural history and thus being able to counsel a patient about not only what should be done, but also if and when it should be done, is critical and is based on trust. 

It is this trust that makes one not only a physician but a healer.  I trust my doctor and for me, his judgment and his caring are critical to the decisions I make.  I still make my own decisions, but his advice is necessary for me to make good decisions. Trust is the key to the ability to time care appropriately which saves money and more importantly, helps people avoid the risks of unnecessary care and the risks of necessary care delayed.    

In an unpublished work (privately shared), Drs Saul Weiner and Simon Auster wrote about the need for physicians to have healing relationships with their patients, in order to engender the type of trust needed for medical care to be successful (and in case anyone has not noticed – successful care is less expensive than unsuccessful care unless of course the unsuccessful care results in very quick and efficient death).  They speak of the need for the doctor and the patient to become one social unit, and the requirement that this relationship happen over time with both the doctor and the patient sharing parts of themselves in ways that creates vulnerabilities.  They describe four characteristics of the healing relationship.

1. It cannot be scripted
2. It evolves with a relationship over time
3. The individuality of the physician, like the patient’s, is central to the direction the relationship takes
4. It depends on trust or, in the initial phases, on the expectation of trust

This of course beings me back to the dance between doctor and patient and the health care cost equation.  The equation, just as a reminder is

Total Population Costs = Volume of Services X Unit Cost of Service

The only way to decrease the volume of services is to build relationships between health professionals and patients that meet the four characteristics outlined by Weiner and Auster.  When I was in medical school, I was taught that my only focus should be the good of the patient whose care was entrusted to me.  The building and maintanence of that  sacred trust relationship was a major part of the education that made me a doctor.  In today’s world, we ask physicians to also think about the health of populations and the reduction of the per capita costs of health care as defined by the triple aim I spoke about in part 1 of this series.  My fear is that in trying to make physicians more aware of the societal needs, we may inadvertently be changing that focus and undermining the trust necessary to save money in health care the right way.

 

I worry that our desire to refocus physicians toward societal goals, and our push to make them focus on the use of technology  may paradoxically work against the goal of lowering costs. As we try to leverage and even replace doctors and nurses with protocols, apps, and systems, do we end up eroding the trusting relationships that are at the heart of medical care?  While the technology and the systems offer many benefits, our challenge is to use them to foster and strengthen relationships and not to try replace relationships in the name of efficiency

Robin Williams and Preventing Suicide

Five years ago this past week, my company Accolade first started helping people through the health care system by opening our Health Assistant Center.  This came only after spending two years developing the new profession of Health Assistant and the systems to support those Health Assistants.  A Health Assistant is a professional trained to form long term relationships in order to help people and their families through the health care decision making process, including  those decisions related to insurance coverage, physician selection, care options, personal health behaviors and all of the life issues which impact and are impacted by health, wellness and illness.  There were many surprises and lessons learned as we improved our ability to form human relationships with people as they were about to enter the health care system and help them along the way. 

One of the biggest surprises that first week was when our youngest Health Assistant, a very bright young woman who is now a leader in our company, took our first call from a person at risk for suicide.  The person was calling for a totally mundane reason, having to do with her benefits when she made a vague suicidal reference that upon assessment by our in house clinical psychologist, turned out to be hallucinations commanding her to kill herself.  This was a first psychotic break for this woman and for the next hour, we stayed on the phone with her, called the Emergency Medical Response team, contacted her sister to come and stay with her in person and had her evaluated and admitted to a hospital.  Following her hospitalization, that same young Health Assistant and our Clinical Psychologist helped that woman get the continuing care she needed.  Five years later, while our Health Assistant is now a leader in our company, she still maintains the relationship with that woman whose life she likely saved that day.  The person has had one relapse which did not need hospitalization and she continues to live a full life.

That was our first experience with helping prevent a potential suicide.  We have found this to be much more common than we would have predicted and now as we help about half a million people who have access to a Health Assistant, we speak with people on the verge of suicide on an average of once a day.  They often start with a benign call.  One stands out in my mind as we were helping a person through an open enrollment process.  Her boss had told her to call her Accolade Health Assistant because the open enrollment period was ending and it was required that she take part in that process.  On a Friday afternoon, this patient called and the Health Assistant first asked about what health care she might need the following year as that would help decide on the best plan for her.  The conversation continued with the person finally telling the Health Assistant that she was not sure that she would be around the following week let alone the following year!  She admitted to severe depression and told of her plan to kill herself.  Our mental health expert immediately joined the call.  On that Friday afternoon, the Health Assistant and our mental health expert stayed with her and made sure that she received the care she needed including admission to the right facility to start her therapy. 

I know that we are not always successful but we do know that suicide, if you are fortunate enough to catch someone at the right time and have the right skills to best assess and engage with these people, can be prevented.  The timing is key and while these telephone conversations cannot achieve 100% success, they are often our best hope.  The assessment often starts by simply listening to the person on the phone.  A clinical “pearl” I learned in medical school was that one should be suspicious of depression if, when you talk to someone, you start feeling depressed yourself.  While the natural reaction when a person feels depressed talking to another is to turn away, we know that is the precise time to stay with that person in need.  We do know that a phone call can be lifesaving when the professional on the phone recognizes the risk of a potential suicide and has the tools and skills needed to facilitate the right interventions. 

In some ways, as I reflect on our experience at Accolade and on the tragedy of a man who gave so much joy to so many deciding to take his own life, I realize that the challenges of treating that creative, quick mind of Mr. Williams may have been too much for any single phone call or any intervention to avoid the newspaper headlines we are now faced with.  I am also reminded of a senior psychiatrist who once told the story of a person he treated for twenty-five years who then committed suicide.  He asked the question of whether his treatment was a failure and answered that his assessment was that he helped that person avoid suicide for those twenty five years so the therapy, while incomplete, could not be called a failure.  I for one will not second guess the health professionals who, presumably, tried to help Robin Williams with his addiction and depression over the years.

But we always must try to intervene, and a simple phone call, as the suicide prevention hotlines around the country and we at Accolade have proved, can be successful in helping people through the depth of despair at the right point in time.  There is a country western song written by Matt Kennon (and I admit to believing that country songs have great truth embedded in them) that may best reflect the power of a phone call to avoid tragedy. 

Today was gonna be the day
He'd already wrote the note
And parked that Chevrolet
At the end of that dead end road
Had his finger on the trigger; just about to end everything
He was taking one last long breathe; when he heard his cell phone ring

And his best friends say man where you been?
We're headed down to the lake this weekend
You better not miss it 'cause buddy I swear
It won't be the same If you ain't there
And I told that girl that you like so much
You were coming along and her eyes lit up
I better let you go man I really hope I didn't catch you in the middle of anything

He said you kinda did but I don't mind at all
I'm glad you called

I have seen over and over, the right phone call at the right time prevent tragedy and I only hope and pray that all who are suffering and alone, make or receive that phone call at the right time to prevent the horror of suicide, for themselves of course but also for all those who care about them.  

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way – Part 1

In May 2008, Donald Berwick and his colleagues wrote about the triple aim of the US health care system.  They wrote, “Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing the per capita costs of health care.”  Today that triple aim remains the goal of those of us in the trenches trying to improve care and access for all Americans.  This is difficult and some would say impossible without real constraints on individual’s decision making.  In that same article, the authors say “Pursuit of the Triple Aim is an exercise in balance and will be subject to specified policy constraints, such as decisions about how much to spend on health care or what coverage to provide and to whom.”   For Berwick and his colleagues, the most important of the constraints is “the promise of equity; the gain in health in one subpopulation ought not to be achieved at the expense of another subpopulation.”  While I agree with that statement I do not consider it the most important constraint.  For me, the most important constraint is that the pursuit of the triple aim must never compromise the individual’s right, working with the health professional, to obtain care in a way that matches their values and their goals. 

I say that because in my thirty years trying to impact this difficult equation, I have seen many well-meaning, and intellectually elegant solutions, that pass the “equity” test however they fail in maintaining individual autonomy and dignity in a way that fosters trust which is a necessary precursor for the best care. 

Ultimately, the value of care, which is inherent in “improving the experience of care” which is the first of the Triple Aim, must be in the eyes of the patient and their family.  If good individual decisions are made by patients and doctors working together the population’s health in aggregate will improve and costs will lower.  We first have to acknowledge, that the Triple Aim as addressed in our society thus far, has focused more on reducing the per capita costs of health care than either of the other two goals as defined.  Lowering costs is extremely important as that allows more people more access to care and best allows for the equity in the system that Dr. Berwick speaks of. 

My starting equation to achieve the cost aim of the Triple Aim is:

Total Population Costs = Volume of Services X Unit Cost of Service

However, I have tried to develop answers and approaches that give equal, if not more importance to the aims of improving the experience of care and improving the health of the population.  That requires obeying the following rules:

1. Maintaining trust between health professionals, patients and families must always be paramount.  Any system that impairs, in any way the trust relationships will make policy solutions unsuccessful.  Ultimately, medical care involves a person putting their life in the hands of another and trust is a necessary pre-requisite.
2. Never lower volume of services across all services, but rather lower unnecessary services.  In other words, lowering health care cost should focus on the cost of avoidable unnecessary care, rather than total cost and care.  While this may seem obvious, our solutions today often take the view that all health care cost is bad. 
3. In order to lower unnecessary services, always understand the real needs of the individual and find the necessary services that best address those needs from their point of view. These are often not related to biology but to emotions, culture, family, finances, time constraints, and competing life requirements. 
4. Do not lower unit costs by devaluing the contribution of trained professionals.  Trying to pay physicians less per service often leads to less personalized, more hurried care, which impairs trust and careful evaluation. 
5. Instead lower unit costs by having the right professionals, working in the right collaborative environment maximize the talent needed for the individual’s issues.  For many problems, for example, that may mean a social worker instead of a physician, or it may mean a community health aid instead of a social worker. 
6. As we optimize unit costs by using the right professional at the right time, never allow any person in need to feel as though they are being “handed off” and always foster the type of coordination and trust that continuously communicates that the patient’s needs and values are paramount. 

In future blog posts, I will attempt to talk about how to potentially succeed at this three dimensional chess game but will also acknowledge that this is no game.  This is people’s lives and families and thus any answers need to be implemented carefully and with study.  My own belief is that as strive for the Triple Aim, as long as we measure everything we do, against the primary “constraint” of maintaining and fostering individuals’ dignity and autonomy, we will succeed.  

Care and Medical Intervention: Are They the Same?

People occasionally need care, and people occasionally need medical intervention.  We often confuse the two.  No one is 100% healthy and we all carry risk of disease, and often live with minor or major symptoms that modern medicine is not equipped to impact.  Many of us live with the label of having a chronic disease.  Despite this, our American culture fosters the myth that all illness and even death is optional, and can be overcome just by our own actions or the right medical interventions. The myth would be funny if the results were not so tragic – both for individuals and for society.  All of us live with the genetic material that our parents gave us; with the risks inherent in where and how we live, and with the realities that life is a fatal illness.  We also all deal with the challenges of living; supporting ourselves and our families, and making our way in an often hard, cruel, and still beautiful world on our personal journeys through life.  What this means is that medical interventions and interactions with health care professionals are unlikely to solve all the problems and life challenges that we often, unrealistically, look to medicine to solve. 

One of the real challenges in medicine is the attempt to tell the difference between a medical problem that can be solved by medical professionals and a problem manifested by physical symptoms that is really a life challenge that must be addressed by means other than medical tests, surgeries, and the latest in pharmaceuticals.  In many ways, the most difficult job in medicine is still the job of “triage” which in its broadest sense, is the ability to assess, or diagnose a person to determine if their symptoms can be helped by the tools and skills that medicine offers.  Since sickness and health are a continuum and there are often few clear lines as to where disease starts and ends the starting point is always the “eye of the beholder” or the belief that the patient in need brings to the appointment with the health professional. 

That belief usually is communicated as a problem presented by the patient, and referred to as the “chief complaint” with the plaintive question to the doctor of “what’s wrong?” and the expectation that the doctor will either wisely give an answer and a medication to fix “what’s wrong” or order tests to determine “what’s wrong’.  The unsatisfying, but often true answers, which doctors rarely give is “you are lonely” or “you are sad” or “you are fearful” or “you are overwhelmed by the problems in your life”.  Instead tests are ordered, a possible “virus” or other medical illness is referenced and a medication is prescribed. 

The fact that the mind and the body are connected and that both mind and body are intertwined with our own personal life environment (mind/body/environment connection) is not given enough attention.  People who present to their doctor, in pain, need care – they may or may not need medical intervention.  They may need care that is more directed towards their emotions and to the true life problems that are presenting as medical illness.  A single mother who has a young child in need of cardiac surgery and who also has three other children to take care of, feed, pick up from school and do all that needs to be done, in addition to needing to showing up at work, needs care when she presents with chest pain and muscle aches.  Chances are, the pain she has is more of a manifestation of her stress and her real human problems than of an impending heart attack.  But how do we know? 

Recently, much has been written about the doctor shortage and a recent blog commented by pointing out that more care does not necessarily mean more doctors.  The article points out how technology and the use of nurse practitioners and physician assistants will change the medical model and create new solutions to the doctor shortage.  While I agree with that assessment, I admit to worrying about the ability to use all these new models, and leverage other health professionals in ways that maximize the skills needed on that front end to determine if the problem is amenable to medical intervention.  I also am concerned that the resultant fragmentation from multiple professionals and multiple communication channels may impair the trust needed to help people in ways that truly address the mind/body/environment elements that are all necessary to care for people.  I worry about team based approaches devolving into bureaucratic confusion for the patient and a “pass the buck” mentality that is already seen in the interface between health benefits, access to care, primary care and specialty care in certain systems. 

Every patient should be assessed and treated with the following elements in mind:

1. Assess and diagnose both the medical and the contextual (social and psychological) issues contributing to the problem
2. If a medical intervention is needed, define a diagnosis plan and a treatment plan in partnership with the patient and consistent with the patient’s values and beliefs
3. Define a care plan distinct from the medical intervention but coordinated with the medical intervention consistent with the patient’s values and beliefs, whether or not it is a medical disease which needs a medical intervention
4. Define an action plan to ensure that both the medical intervention plan and the overall care plan are followed.
5.  Identify the right professional with the right skills to implement the medical plan, whether that means surgery, a procedure, or medication management. 
6. Identify the right professional to provide the needed encouragement and coordination needed to implement both the medical intervention plan and the care plan.
7. Follow through relentlessly on both the medical intervention and the overall care plan as the bumps in the road can easily derail both.

To effectively accomplish these steps, you need skilled professionals and you need to gain and maintain the person’s trust that the medical treatment plan and the care plan as developed will help.  You need physician skills, nursing skills, social work skills, mental health skills and even insurance and benefits skills.  You need diagnostic acumen, cultural competency, communication skills, coordination skills and the skill to build and maintain a relationship.  While in the past, a physician was expected to have all of those skills, we now know that these skills are often best done by those with a myriad of different training, and can be facilitated with technology.  The real challenge, is how to put all this together, in a very simple way that fosters trust and involvement for all those in need of care.   The high level opinions on the need to leverage professional talent and technology must address exactly how this is accomplished so the person at the center of all this effort, actually benefits. 

As we think through all the pieces of this complex puzzle, let’s make sure that we focus on building trust, understanding an individual’s values, culture and beliefs, and accurately assessing their medical and their care needs.  We need to think through the best way to accomplish that in ways that are both effective and efficient.  We also need to think carefully about how to combine all the skills and professionals in a seamless, simple way.  Until we understand all that, I will continue to maintain my very traditional strong relationship with my primary care physician and pray that I stay healthy.  

How I Spent My Summer Vacation and the French Paradox

I have just returned from a wonderful, enlightening and exhausting trip to the Brittany and Normandy regions of France.  The trip was centered on my second son’s wedding to a young woman from France.  This wedding in France included parents, relatives, friends and was carefully planned to be an amalgam of the French, American and Jewish traditions and cultures that their union represents.  The outdoor farmhouse setting in the French countryside, an hour from Nantes in the Brittany region on the border of the Loire Valley was extremely French as was the meal.  The marriage under the Chuppah, the traditional Jewish wedding canopy and the Jewish wedding vows were very Jewish.   The music incorporated a Klezmer band and a DJ playing standard American selections as well as French music.  It was a fascinating weekend and a very successful meeting of the different peoples and cultures. 

The wedding meal especially, was fascinating to me, as someone who cares about nutrition, health risks, and the cultural aspects of health.  It was eight courses (and please don’t ask me to remember and describe each course as the wine with the courses make that sort of memory impossible) and lasted six hours.  For those six hours, the music did not play and the focus was on eating, talking and enjoying each other’s company only interrupted by the occasional toast and the videos of the bride’s and the groom’s childhoods.  The French guests enjoyed every minute savoring each bit of food and the American guests couldn’t quite figure out what was going on.  The American mind set and frame of reference was one of eating rapidly and eating a large amount at times of joy, while the French mind set was one of savoring each bite, taking time with each course, and generally focusing on the taste of each unique food that was part of the admittedly small portions of each course by American standards but totally generous meal when measured in its entirety.  For the French, any one course that was too large would only hurt the enjoyment of the next course. 

While this meal was unique as a wedding meal should be, the manner in which it was eaten was fairly typical of what I observed during the rest of my and my wife’s travels through the villages, towns and cities of Brittany and Normandy.  A meal in any of these locations was an event to be savored, and enjoyed over time.  It was noticeable that this held true for everyone, not only the tourists and vacationers.  In most villages, stores would close for two hours in the middle of the day so that the storekeepers could take their lunch in the “correct” French way, slowly and focused on the quality of the meal that was being eaten.

 

The manner in which food is approached and eaten and the significance of the meal is clearly very different in France than in the United States.  One person I met who lived in the city of Bayeux, told me that his grandmother would spend at least five hours a day on food preparation and the remainder of the family time appeared to be related to conversation about food and upcoming meals.  Traditional French food uses a great deal of butter, cream and animal fat, and would be considered by US standards to be unhealthy however it is also very tied to natural ingredients and to the use of primary sources – sourced from local farms, bakers, and other food producers. 

Considering the high fat content of the food in France, the phenomenon of the “French paradox” has been well described for many years.  In an article in 2001 by Jean Ferrières entitled, “The French Paradox: lessons for other countries”, the author defines the paradox as the observation that coronary heart disease death rates are low in France despite high intake of dietary cholesterol and saturated fat.  There has been a great deal written on the reason for this paradox from the high red wine intake, to the complex behavior and attitudes towards food that I observed during my travels. 

There are those who argue that the French paradox does not exist at all and the differences seen are just a statistical aberration however proof of that contention has been difficult to elucidate.  Michael Pollan, in his book “In Defense of Food” published in 2008, suggests the French paradox is due to the nutrients found in “natural” foods as opposed to “processed” foods.  Pollan advocates an approach to food in general that culturally may have more similarities to the French way of eating than to the American norm. 

There is no simple answer to the paradox and it appears that many factors, including perhaps different statistical methods, all contribute.  Whatever the reason for the statistical paradox, I believe that the traditional French way of eating, with its focus on eating slowly, focusing on the taste of each bite and on the quality of the food instead of the quantity, has some role in the lower incidence of death from heart disease.  Smaller portions are the norm, and the ability to enjoy the eating experience, I believe, is a part of the answer.  French people I spoke with fear that this cultural approach to food is on the decline as the pace of life becomes more frenzied and more Americanized.  That is reflected in recent statistics on obesity increasing in France. 

If there is a lesson to be learned, it is the lesson that how you do something, such as eating, is often as important as or even more important than what you do.  You can eat food that appears to be less healthy but if you eat more slowly, eat smaller portions, and consider food intake to have a social dimension that does not allow the “eating on the run” and the mega-portions that are part of American life you are likely to be healthier. 

That is a lesson that extends beyond diet to all aspects of life.  As we discuss health care in general, and we focus on evidence based best practice and standardized care, we must stop and think about whether a singular focus on what we do, rather than how we do it, will hurt us in the long run.  For me, I return to the United States, having eaten my way through northern France, and weighing less than I did when I left for my trip, convinced that I will try to adjust my eating to be slower and more aware of what I eat, and perhaps to drink a bit more wine as well.  I will also adjust my thinking to stay focused on the “how” as well as the “what” in all aspects of life including my professional life in health care.  

A Purpose Driven Company

I admit that I have great pride when I see my children quoted.  However my reason for sharing this particular article which references the second of my four children, is about the message that he gives and how it applies to my own company, Accolade, and to all organizations involved in health care. 

Accolade was built as a purpose driven company, with a goal of helping people through the complexity and confusion of health care by creating a new profession – the profession of Health Assistant.  We were built with the vision that every person in the United States will someday have a Health Assistant and that Accolade Health Assistants will be the best in the world supported by the best systems and the best organization. 

In this particular article, Rob is quoted as saying about Good Eggs, his company, “we’re a company full of folks who are doing this because [we] want to make the world a better place.”  That also describes all of us at Accolade and it describes how all people building new health care organizations should approach the tasks before them. 

In CSR Wire, the Corporate Social Responsibility Newswire, Rob describes eight lessons on how to build and run a purpose-driven company.  All of you who are trying to build health care organizations, either as new entities or within established organizations should think about these lessons as you approach your missions of helping those in need.

Medical Myths and Asking the Right Questions

Last week, I started my blog post with the statement that “Doctors are people.”    There are many medical myths and the one I was addressing in that post was the myth that physicians have some supernatural power that makes them more than just people.  Dr. Robert Pearl, the CEO of the Permanente Medical Group, in the latest installment of his “medical myth” series of blog post in Forbes attempts to prove  that the statement “medicine is an art, not a science” is a myth.  The fact is that medicine when practiced optimally must be both. 

He starts by asking the question whether medicine as an art or a science saved more lives.  His answer is that science has saved more lives and therefore medicine as an art must be considered a myth.  Whenever you have the opportunity to ask the question in the way you want, you can always produce the result you want.  Just ask any pollster.  The question he asks is written from a population health management point of view, not an individual patient care point of view.  The answer becomes more nuanced when the question is changed.  Let’s look at the three examples he gives. 

His first example is treating people with stroke and he rightly points out that when guidelines developed by the American Heart Association in conjunction with the American Stroke Association are used by hospitals to standardize admitting orders, then the outcomes are better.  Science therefore triumphs.  However a major factor in the use of those guidelines calls for patients to get to a center that can effectively treat them in a very short time.  Delay, in this case, kills.  Quick action demands faith in one’s doctor and in the health system and also demands that the access to care is simple and perceived by the patient as helpful.   A different question to ask in this case is whether art or science will help people access care at the right time and at the right place in order to take advantage of the best practice protocol.  The art of medicine requires that patients know their doctors and other health professionals, trust them, and therefore reach out in a timely manner when care is needed.  That is a precursor in this instance to using the right protocol once someone is in the hospital.  Unless physicians pay attention to the art of medicine, gain people’s trust, and give them the confidence to reach the right facility soon enough, the scientific efforts are worthless.   

The second example he talks about is the use of beta-blockers, ACE-inhibitors, aspirin and statins after a heart attack to reduce the risk of future heart attacks.  He cites the fact that “the best doctors prescribe these medications 98 percent of the time.”   However he neglects to mention, that when a physician prescribes a medication, that is only the start of the challenge of ensuring that the patient takes the medication.  A different question therefore is whether the art or science will help the patient take the medication as prescribed.  The patient may hate taking any medication and may not believe that the beta-blocker will help.  A friend may have told them of a bad experience with the same medication and they may be afraid to take it.  The patient may have a benefits plan which requires a co-payment that they cannot afford.   The art of medicine requires that the doctor know the context of the person’s life, their values and beliefs towards the therapy, and the potential barriers that are present that may affect the patient carrying out the doctor’s instructions.  It requires the doctor to think past the protocol and help address the life issues in a way that respects the patient’s beliefs and values. 

His last example is the setting of protocols for the operating room.  Again those protocols are necessary and the science behind them is compelling.  However an experienced, knowledgeable surgeon, who is able to react to the changing situation in the operating room, using experience and the art of medicine, is often necessary.   A different question therefore in this case is whether the art or science will help in assessing any surprises in the OR.  In his editorial in the WSJ entitled, “The Bureaucrat Sitting on Your Doctor’s Shoulder”, Dr. Zane Pollard from Scottish Rite Children’s Hospital in Atlanta tells of a case in which in the operating room, he had to change his surgery due to findings that were unexpected.  He was not paid and was cited for performing a surgery that was not part of the protocol that was approved even though he clearly did what was right for the patient.

The best medical care never makes a choice between the art and science of medicine but rather uses both to benefit the patient. Dr. William Osler, considered to be the father of modern scientific medicine said, “The good physician treats the disease; the great physician treats the patient who has the disease.”  He also said, “Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under that abnormal conditions we know as disease.” 

Dr. Pearl’s examples and questions to prove his point are all about populations and disease.   If the questions we ask, and the metrics we use, are only about the populations and about disease and not about the “patient who has the disease” in Osler’s words, we will miss major aspects of care.  If they are only about what goes on in the doctor’s office and in the hospital and not what happens before someone arrives at the hospital and after they leave, we may actually cause harm to the patient even if we improve our population numbers.  We must practice both science and art: we must follow scientific protocols diligently and use the communication skills, the assessment skills and the trust building skills that are all part of the art of medicine.  We must partner with people and understand how the disease impacts their lives, and how their lives impact the treatment of the disease.  The real myth is the belief that medicine is either art or science when it must be both.