Surgery, Family and Post-Operative Care

In the eyes of parents, children are always children, even when they are grown.  So when our youngest son, 20 years old and a junior in college, needed sinus surgery, my wife and I drove the 7 hours to see him through the surgery and take care of him.  That is what parents and families do.  As a physician and as someone who routinely searches for best physicians and facilities as part of my job, I had investigated the surgeon and the facility and had decided that he should have his care in the city where he goes to school. 

The surgeon was perfect.  Caring, skilled and communicative.  The facility and the health system was excellent.  The surgery was less straightforward than we had hoped, as his obstructed sinus was profoundly infected with abscess formation.  The skill of the surgeon and the operating team was a blessing as operating on infected tissue is always more difficult.  Thus the one hour surgery turned out to take three hours.  Our son came out of surgery and after a few hours in the recovery room and in the extended care area, we took him back to our hotel, as we thought we could better care for him post-operatively there than in his student apartment. 

We walked him into the hotel, supporting him on either side.  He was shaky on his feet as one would expect after hours of anesthesia.  He had been intubated (had a breathing tube inserted into his trachea) during the surgery so his throat was sore and his voice very weak.  No surprise there.  In the hotel room, we were busy changing the dressing under his nose (a so-called “moustache” dressing) which was catching the bloody discharge from his nose, and also helping him deal with some difficulty with urination, also no surprise after anesthesia and surgery.  We were helping him stay on top of his proper pain medication dosage and anti-nausea medication.  We gave him the antibiotics he needed at the proper time intervals.  And then it hit us.  My wife and I are doctors.  We are used to these issues and feel very well equipped to provide post op care and post op monitoring.  But what if we had no background in medicine?  What if we were accountants or store clerks, or engineers or bus drivers who suddenly had to be thrust into this role?  Would we feel as confident and comfortable?  What if the patient had no one to help them, with a friend driving them home and then leaving them alone for the rest of the evening, night and days to recover?

We were keeping him hydrated, pushing fluids.  We were watching him to make sure the bloody discharge did not suddenly turn into bleeding that would be much more serious – even potentially life threatening.  We suddenly understood emotionally the truth of the adage that people in our modern era were discharged from hospitals “quicker and sicker”.  We intellectually knew that people, who had day surgery, were sent home from the hospital often in need of care, even if they were not in need of hospitalization.  The norm today is for that care and monitoring to be provided by family and friends with little training and support in those often critical first 12 to 48 hours after surgery.  Rarely do medical facilities, no matter how good, review the adequacy of that caregiver as they discharge the post-operative patient to home.  

The facility where he had the surgery had done everything in a world class way.  The instructions given to us upon discharge were thorough and clear.  The surgeon had given us good explanations and instructions and had personally called our son the first day post operatively to check on how he was feeling.  Everything was done the way it is supposed to be done.  The problem from our prospective – from a family prospective – is the profound emphasis on efficiency by the rules of the payment systems and the minimizing of the human element of families caring for loved ones. 

Thorough instructions do not take the place of experience and training.  The care of someone with dressings, with pain management, and with all of the issues related to bodily functions are no longer seen as being efficient when done in the hospital.  Those activities do not reach the level of care that meets criteria for skilled home care.  But at the same time, patient and family fears and uncertainties are not taken into consideration.  The risk of being alone is not addressed.  Instead, the families are forced to take on roles for which they have no training and no skills.  Patients are believed to have the ability to monitor themselves.  It is believed that providing reassurance around wound drainage, expected post-operative pain, and family’s worries that the healing process may not be progressing as normal, is just not efficient. 

My belief is that from a cost point of view, this responsibility given to patients and families leads to unnecessary ER visits and unnecessary readmissions as the caregivers often do not know how to deal with a loved one, having just gone under the knife, who complains of pain and other symptoms.  Even though on paper, criteria may make sense, when they don’t take into account the experience, knowledge, and fears of the family caregivers or the lack of any caregivers, they are not adequate and can lead to poor clinical outcomes and ironically higher cost.

Our son is now doing fine, and I feel great gratitude and admiration for the surgeon and his team.  On a broader scale, I worry about whether our push for efficiency in health care has actually hurt our quality of care and paradoxically increased costs.  I worry that we may be minimizing the caring, understanding and empathy that are necessary components of health care.  I worry that we may not be paying enough attention to the informal and untrained and unpaid caregivers who now must do so much of the monitoring and care.  I worry that even as we improve the quality of care inside facilities; we ignore the fact that patients go home and are still sick and need care and monitoring.  I hope and pray that we find ways to address my worries in an increasingly population based medical care system.  

Biology and Culture in the Treatment of Ebola

We are starting to make progress against Ebola.  But those who believe it is because we have developed new treatments or vaccines, would be wrong.  We are still struggling to find the right treatments, and still doing research on an accelerated time table to try and find vaccines for this rapidly mutating virus.  Rather, we are making progress because we are fighting the disease using basic principles of public health while paying closer attention to the cultural aspects involved in both the spread and the control of the disease.  In a study done in “Emerging Infectious Disease” in October of 2003, during an earlier Ebola outbreak, Barry Hewlett and Richard Amola explained how the local population in Northern Uganda both explained and treated Ebola using local beliefs and customs and the wisdom of traditional healers.  Contrary to Western biases, the authors found a great deal of pragmatism and flexibility in the local healer’s approach and found that local cultural and religious norms could have a positive effect on the control of an outbreak.  The local healers led efforts, which appear to pre-date Western influence in Uganda that are very much in keeping with modern methods of infection control.

“When an illness has been identified and categorized as a killer epidemic (gemo), the family is advised to do the following: 1) Quarantine or isolate the patient in a house at least 100 m from all other houses, with no visitors allowed. 2) A survivor of the epidemic should feed and care for the patient. If no survivors are available, an elderly woman or man should be the caregiver. 3) Houses with ill patients should be identified with two long poles of elephant grass, one on each side of the door. 4) Villages and households with ill patients should place two long poles with a pole across them to notify those approaching. 5) Everyone should limit their movements, that is, stay within their household and not move between villages. 6) No food from outsiders should be eaten. 7) Pregnant women and children should be especially careful to avoid patients. 8) Harmony should be increased within the household, that is, there should be no harsh words or conflicts within the family. 9) Sexual relations are to be avoided. 10) Dancing is not allowed. 11) Rotten or smoked meat may not be eaten, only eat fresh cattle meat. 12) Once the patient no longer has symptoms, he or she should remain in isolation for one full lunar cycle before moving freely in the village. 13) If the person dies, a person who has survived gemo or has taken care of several sick persons and not become ill, should bury the persons; the burial should take place at the edge of the village.”

Yet during that earlier outbreak in 2003, the traditional healers’ approaches to disease control was assumed to be destructive to the enlightened Western approaches.  It was assumed that the local traditions contributed to the spread and that those local beliefs and approaches had to be challenged and discarded. 

In the current outbreak, the same cultural arrogance, and belief in the Western approach being the only acceptable approach, may have initially hindered early progress on disease control.  As an example, one of the factors that is believed to have contributed to the spread of Ebola has been the local burial practices.  Muslim burials in West Africa, are traditional and involve a ritual washing of the dead, a practice that Muslims and Jews have in common (as is true for many practices of Muslims and Jews).  In addition in some cultures of West Africa, during the funeral, touching the face of the dead is also done as a way of showing their love.  Yet research has also shown that people are willing and ready to modify those burial practices if the changes are done with respect for beliefs and the involvement of local religious leaders. 

A new protocol that has been instituted by the World Health Organization addresses these burial practices but does so in a way that respects the cultural and religious beliefs of the mainly Muslim and Christian communities that are now being affected so severely by the disease.  As reported in the New York Times,

“The new protocol emphasized that burials needed to be safe, but also dignified, taking account of religious and cultural sensitivities to build trust in communities where some people have accused burial teams of spreading the disease. Inviting the bereaved to be involved in digging the graves of relatives and offering Muslim families an alternative to ritual washing of the dead, a practice that could involve lethal exposure to the virus, “will make a significant difference in curbing Ebola transmission,” the W.H.O. said.”

Alpha Kamara, a journalist who lives in Sierra Leone in a piece published in USA Today describes this interface between religious faith and medical care quite eloquently from a Christian prospective quoting the book of Joshua.  He states:

“Joshua 1:9 reminded me that although God can be everywhere, Ebola cannot.  God can command.  Ebola cannot……. Ebola is a virus.  We react to it.  But we can control our reactions.”

He goes on to states his thanks to OXFAM, the World Health Organization, UNICEF, and Doctors without Borders who have done so much for the people of Sierra Leone.  Those organizations are at the forefront of caring for people in both a scientific and a culturally and religiously sensitive way.

Without the trust built through protocols that respect beliefs, and the attention to the cultural issues in health care, the work of worldwide health organizations and protocols such as this new protocol for burial practices would not be as successful and would not be able to decrease the spread of the disease as it appears to be doing.  Without the blending of science, faith and culture, we could not vanquish this virus.  If this were a pure biologic approach that did not incorporate local religions and cultures while respecting local leaders it would not have the kind of success that is needed. 

Medicine, wherever it is practiced, must start with trust and respect for the patients and their beliefs.  That includes understanding and respecting their cultural and their spiritual selves as well as their biology.  Without that starting point, the best biologic research and treatment in the world, will never be as successful as it can be. 

Playing 3 Dimensional Chess: Saving Money in Health Care the Right Way Part 4 – Impacting Emotions

“The good physician treats the disease; the great physician treats the patient who has the disease”

Dr. William Osler

We are all emotional beings.  Emotions are necessary and part of the human condition and are associated with illness of all types.  This is so self-apparent that people who lack certain components of emotions are considered to have a disease.  Whether someone lacks fear and tends to put themselves in danger or lacks empathy and tends to put others in danger, they are seen to be at a significant disadvantage in life.  Thus it is no surprise that people have emotional responses when they are in pain and when their body is overcome by changes due to disease.  These normal emotional responses to disease are actually helpful as we adjust in order to effectively deal with the challenge of being sick.  But while small doses of fear, anger, sadness, and other emotions are helpful, so too can they be destructive when they move into the realm of full blown depression, anxiety and denial that can signify a need for active treatment.  Even when the emotions do not reach that level of distress, they still must be acknowledged and addressed so that they do not lead to bad decision making when accessing care.  A person who is frightened can rush to an Emergency Room when waiting a day to see a primary care physician can be a better decision.  A person in denial can avoid needed immediate care and end up with severe consequences.  While neither situation may raise to the level of full blown emotional illness, they can adversely impact care. 

The interplay between medical illness and emotions has always been a part of medicine.  In recent years, with the emphasis on efficiency and adherence to disease protocols, the emotional aspect of treating illness has sometimes not garnered the attention it deserves when one visits a doctor or a hospital.  But a number of researchers have continued to look at the interplay between emotional illness and medical illness.   A classic article published in the New England Journal of Medicine in 2010 by Dr. Wayne Katon and his group showed that by combining support of chronic medical illnesses such as diabetes and heart disease with better treatment of depression and other behavioral diseases, clinical results were vastly improved.

 

Dr. Katon, with his work, coined the phrase “collaborative care” to describe a combined medical emotional approach to treating patients with illness and described three needed components to good collaborative care; a population approach driven by standard metrics for both the behavioral and the medical problems, monitoring of adherence by patients, and the use of “stepped care” or intensification of therapy if patients are not responding to therapy even when they are adhering to their treatment.  While poor adherence is often an issue in poor outcomes, a lack of proper monitoring and an inability to intensify therapy as needed are more likely to cause failures of treatment. 

At Accolade, we have made the use of collaborative emotional and medical support a cornerstone of all that we do to assist our clients.  In a commentary written in 2012 in the American Journal of Preventive Medicine, Dr. Katon cited the use of multi-condition managers to enhance quality of care.  At Accolade, we have used this type of model since we started helping people more than five years ago.  To quote his commentary:

“Several studies have expanded the concept of collaborative depression care by training care managers to enhance quality of care for depression and common comorbid conditions such as hypertension, diabetes, and coronary heart disease.  These new multicondition collaborative care models may provide economies of scale to treat multiple common primary care conditions.  Rather than primary care systems needing a separate care manager for each illness, which may be prohibitively expensive, multicondition care managers can provide enhanced quality of care for the most common medical conditions in a cost-effective manner.”

The key for us at Accolade is to expand that concept even further and recognize the patient as a person with medical, emotional, financial, spiritual and social needs.  We help the person address all those needs in a dynamic, ongoing way.  The data that shows that adherence and stepped-care are both important means that a relationship based case management approach is needed to remind about adherence and to maintain a patient’s trust so that if treatment is not effective, he or she can be coached and helped to return to the care giver in order to be properly assessed for intensified therapy.
 

While this results in improved care, the question is whether it saves money.  An article from the American Journal of Preventive Medicine by a group at the CDC suggest that the savings from this type of collaborative care approach can be significant.  By performing an in depth analysis of previous studies, they found that savings per person could reach levels of from $1,000 per person to $4,000 per person.  Their conclusion was that collaborative care provides good economic value. 

Saving money in health care paradoxically often means doing more, not less.  In the case of emotional reactions to illness, the need to proactively identify, monitor and treat the depression, anxiety and even the fear that is part of being sick results in higher quality and lower cost interventions.  This is one more example of Osler’s dictum that the great physician, and in our case the great health assistant, treats the person who has the disease.  This results in saving money in health care the right way.  

Bias, Fear, and Health Care

Dr. Leana Wen is a wonderful physician and author (as well as a member of the Accolade Medical Advisory Board) who is a recognized expert on the role of communication in medical care.  In a talk she gave in May of this year at TedX Foggy Bottom, she spoke, for the first time, about her own experience as a stutterer and the paralyzing impact of the shame and fear that the stuttering caused.  Stuttering, for Dr. Wen, is just as important to her identity as her being Asian-American, being a woman, and being a physician.  It is part of the complex tapestry of who she is as a person and how she is seen by others and how she sees herself.  Each one of us is an amalgam of   traits, beliefs, attitudes and histories that defines us for the rest of the world and shapes our own perception of how we interact with the world.  This complex dynamic of the world’s perception of a person combined with a person’s own perception of what makes them unique can dramatically affect every aspect of our lives, including our health care.  In the latest issue of Health Affairs Dr. Wen builds upon her TedX talk and tells a story of a patient who is also a stutterer who initially receives sub-optimal care for chest pain due to his stuttering.  When the care is transferred to Dr. Wen who recognizes the trait and adjusts the evaluation and treatment accordingly he receives the right care. 

The way others see us and the way we see ourselves can create barriers to receiving the right care at the right time.  In the case that Dr. Wen describes, the first ER doctor saw the intelligent lawyer who stuttered, as someone who was slow, possibly even mentally impaired, and that created a risk that the care to be rendered could be misguided and wasteful.  Dr. Wen was called in to obtain blood tests and x-rays to evaluate the patient’s chest pain however when she was able to communicate with the patient in a trusting, caring way, he needed neither as the problem was not what it initially seemed to be.  Rather he had found himself in the ER with a diagnosis of chest pain due to his being in a situation in which his fear of stuttering created a panic attack.  The blood tests and x-rays were unnecessary and after his evaluation, he was able to go home.  It would have been no different if the issue was a language barrier, a manner of dress, or even someone’s race giving rise to bias. 

While bias in health professionals is a problem, it is only part of the problem.  Each of us also has a trait, belief, or other feature that cause us to feel fear and to block our ability to achieve all that we can achieve.  That fear can be related to race, family background, or physical disability.  It can be based in personal or historical reality or just be a perception that has no basis in anything overt or obvious.   I am a Jewish child of immigrants and while I take pride in that pedigree, when I was growing up, it also elicited a certain fear in me and led me, to sometimes feel as an outsider in the medical circles in which I worked and lived.  When I started medical school I had to get past the feeling that every one of my classmates was tall, with blond hair, had parents who were alumni physicians and had gone to Yale (since over 20 people in my class of about 150 at Columbia had gone to Yale it had a bit of a basis in reality).  Externally, when I was growing up, I faced some overt anti-Semitism and while not enough to be material, when combined with my family history of uncles and aunts being killed in the hell of Auschwitz, the fear that it elicited was very real.  My father, my hero, lived with a certain amount of fear that was founded on the reality he lived with when he was in Europe helping others escape from Germany and he passed some of that on to me.  He also passed along the bravery to stand up to the fear and take the kind of risks only an immigrant coming to a foreign land with nothing could take.  While that may seem disconnected from the stuttering that Dr. Wen describes, the fear that was part of my family history was a self-perception that sometimes caused me to be treated differently and to hold back when I should have been assertive.  It was my stuttering.  In a critical illness situation, that can be dangerous.

In health care, which is so personal, the external reality of bias for any reason, and the internal feelings of fear, can lead to care that is bad, dangerous and often more costly than it should be.  In May 2013, I wrote a blog post about my son’s hospitalization for a unknown illness, and the perception of the staff that his illness was not serious, or was somehow his own fault (the illness actually turned out to be secondary to an unusual disease totally missed by the staff at the teaching hospital).  The bias that they developed, just based on their assumption of who they thought he was hurt his care.  Happily, his own self-perception was strong enough, that he could overcome that barrier to get the right care at a different health system after discharge and be treated successfully.

 

The combination of health professionals who put a “label” on anyone, for any reason and the fear brought on by a self-label can be deadly, but they both can be fought.  A person, who recognizes the bias in a health professional, even if inadvertent, can point it out to the doctor, nurse or therapist and in most cases, the professional will probably apologize.  Thus the “disease” of bias, which affects care, can be countered, just as it was in the case related by Dr. Wen in the Health Affairs article.  If that doesn't work, then quietly demanding to be treated as an individual and not as a perception or a label may be needed.  Often the harder job is attempting to overcome the internal self-images that tell you, in a soft voice, that you cannot succeed so you don’t even try.  In those instances, just as Dr. Wen uses that self-image of being a stutterer to help her succeed, so others can be coached and supported to embrace who they are and to turn the fear into a strength.   In a person’s journey through illness, both the health professional and the patient have to be ready to face their own biases and their own perceptions head on to obtain the best care.  

Communication as a Valued Skill in Patient Care: The Need for a New Profession.

The Curse of Knowledge.  We tend to think of knowledge as a positive attribute, and we are right, however every positive attribute has within it the challenge of the attribute being used correctly and sensitively.  In a recent commentary in the Wall Street Journal entitled “The Source of Bad Writing” Steve Pinker describes this curse, defined as a “difficulty in imagining what it is like for someone else not to know something that you know” as a source of much of the bad writing that we see.  He wrote:

“Anyone who wants to lift the curse of knowledge must first appreciate what a devilish curse it is. Like a drunk who is too impaired to realize that he is too impaired to drive, we do not notice the curse because the curse prevents us from noticing it….. I go to a website for a trusted-traveler program and have to decide whether to click on GOES, Nexus, GlobalEntry, Sentri, Flux or FAST—bureaucratic terms that mean nothing to me. My apartment is cluttered with gadgets that I can never remember how to use because of inscrutable buttons which may have to be held down for one, two or four seconds, sometimes two at a time, and which often do different things depending on invisible "modes" toggled by still other buttons. I'm sure it was perfectly clear to the engineers who designed it.”

While his message is about writing, it also applies to medicine and to the communication that is critical to good quality medical care.  Medicine is a field of endeavor in which sensitive topics require strong communication, however, the curse of knowledge has infected medicine through policies, regulations, economics and medical education. Medical professionals are trained to learn a highly specific language and we don't give doctors the time, training, and incentives to communicate. We also seem to be stuck in a destructive cycle in which the cost of giving physicians and other health professionals the time and tools they would need is assumed to be too expensive in our resource stretched world, so the problem keeps getting worse. However, while we act otherwise, it may actually be less expensive to give health professionals more time with patients because we often substitute tests, drugs, and procedures for communication.  Many of the concierge medical programs and the direct primary care approaches are starting to prove that the most expensive part of the health care bill is not necessarily the increased time per office visit. 

Giving doctors, nurses and therapists more money for more time, as the only solution, will not solve the problem.  I worry about the challenge of retraining doctors who have been taught that the communication aspect of treating patients is not important.  The current system is driven by an almost religious belief in science alone and dedicated to the precision of scientific language which is often incomprehensible to those who are not in medicine. We must try to change the culture in medicine and in medical teaching environments that lauds the medical scientist as the final arbiter of all that is high quality in medicine. That being said, the science is critical, and we should not be compelled in this cultural change to devalue the science. But we must regard the caring and the communication as being of equal value to the science.

I know this will be challenging. It is extremely difficult to change the culture of medical education in which physicians huddle outside patient rooms around computer screens, discussing among themselves the diagnostic dilemmas and the therapeutic challenges that the pathology, not the person, presents. It is also extremely difficult to change the insurance rules and payment systems and the culture of insurance, government and health policy which speaks in the language of "incentives" and "codes" and "adjudication", rather than the language of “caring” and “understanding.”  It is virtually impossible to change a medical science and industry infrastructure that looks for a complex medication or a new technology or a new payment methodology rather than looking for a better way to relate to people as people.

Yet we will not improve care and caring for people unless we start to focus as much on changing this culture of purist medical science to one that values communication, story telling, and the social and psychological aspects of people's lives.  We can learn lessons from Pinker’s message and from literature in general about communicating with people’s spirits as well as their minds.

Dr. Daniel Sulmasy, a Franciscan monk, physician, author and expert on medical ethics, has written extensively on the need to see the experience of illness as distinct from the disease pathology.  He wrote:

“Illness is a spiritual event. Illness grasps persons by the soul as well as by the body and disturbs both. Illness ineluctably raises troubling questions of a transcendent nature-questions about meaning, value, and relationship. These questions are spiritual. How health care professionals answer these questions for themselves will affect the way they help their patients struggle with these questions.”

It is spiritual, it is literary, it is story-telling and of course it is scientific. Health care touches people as people and not only as patients.  As such, we must find solutions that fosters the caring, the communication, and the literary and spiritual aspects of care as well as the purely medical science aspects. 

My solution is somewhat radical but also keeping with the tradition of medicine in human history.   A new health professional dedicated to hearing people's stories, relating the stories people tell to professionals in ways that influence the care they receive, and helping those people in need by translating the jargon of insurance, care delivery and medicine, into understandable and actionable prose that reflects their lives, their challenges, their values, and their fears. A profession that recognizes the spiritual nature of illness as well as the scientific aspects of disease.  We, at Accolade call the professional who has this communication expertise the Health Assistant and lest this blog seem too much like a shameless commercial, our goal is to create this new profession in addition to growing Accolade as a company. Of course I want to see the success of my company, but more as a vehicle for changing the landscape of medicine than as a purely commercial endeavor.  Our patients need and deserve this. We all, as people, need to be approached with a dedication to true communication that matches the dedication to medical science.

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

As patients, we all want our doctors to be smart and caring, and to focus all of their attentions on helping us as we struggle with illness.  We want our primary care doctors to take their time with us, allowing us to tell our stories and to fulfill their role as our trusted advisor and advocate as we traverse the health care system.  We want them to be clinically aware of all the implications of what we say, to be able to assess us with their skilled physical examination and to be able to choose the right tests and therapies to treat us.  We want them to help us access the right specialty expertise when that is warranted. 

We want our specialists to have in depth knowledge and skills so that if we put our lives in their hands, we will be confident that we will come out of our interaction with them better and healthier than when we started.  We want their technical expertise to be excellent and their judgment to be impeccable when our lives are on the line.  We want our surgeons to have gifted hands and gifted minds to go with those hands.  We want our cardiologists, our endocrinologists, our pulmonologists and our gastroenterologists to be able to assess and treat our illnesses when those illnesses fall into their areas of expertise and we want them to have the wisdom to know when our problems are not in their areas. 

We as patients want our clinicians to follow the advice of Dr. Daniel Sulmasy who states  in his book, “The Rebirth of the Clinic” that our clinicians should “concentrate on the basics, becoming again who we always have known we should be – physician, surgeons, nurses and others who are full of care; humble, sincere, compassionate, and competent.”  

But it must be acknowledged that the costs involved are real and impact other family needs from housing costs, to food, to the ability to care for families.  So costs cannot be ignored.  As I stated in part 2 of this series on saving money in health care, costs are generated when a patient meets a health professional and decisions are made which generate claims and bills and ultimately costs.  The smallest part of the costs generated by a visit to a doctor are the fees that are charged for seeing the physician.  The testing, the therapies, the surgeries, the imaging and the facility charges make up the bulk of the services that costs all of us so much.  Payors need to better understand that dynamic and try to pay physicians and other health care professionals in ways that foster what patients want, which is for clinicians to use their knowledge and skills to help make decisions that best help the patient.  Does the reality of our payment and incentive system actually match our desired outcome when a patient sees a physician? 

Many years ago, I used to speak on the topic of how to pay and incent physicians.  With my tongue firmly in my cheek, I would always say that there are three ways to pay a physician.  One is to do less, one is to do more, and one is to leave at 5 PM.  When you pay a doctor a fixed fee per patient, whether the patient is seen or not, often called “capitation”, you are paying them to do less.  When you pay them a fee per service, and allow individual services, such as ECG reading, blood drawing, and physical exam to be separate services and therefore billed separately, then you are paying them to do more.  When you pay them a salary you are paying them to leave at 5 PM.  The point I was attempting to make when I would say this was that doctors are people and we need to acknowledge that they work towards incentives just as all people do. 

At the same time, patients (and we are all patients at times) often don’t want doctors and health professionals to be ordinary people.  We, as patients want them to be more.  We want them to fulfill a calling and to understand their standing in our society as occupying a position of trust that is a both a privilege and a responsibility.  It may be a bit overwhelming to try and think of developing an incentive system that recognizes and encourages that sense of professionalism that leads to the calling being fulfilled; however we must try.  Our current incentives do not succeed at fostering this sense of professionalism. 

The language used to describe clinicians has changed and incentives are driven by the language.  They are no longer doctors and nurses caring for those in need.  They are no longer clinicians but “providers” and patients are not patients but “consumers”.  The language of caring and healing has gone by the wayside to be replaced by the language of economics.  Society has allowed the MBAs (and I say that as a physician with an MBA who takes great pride in that degree) and the economists to suck the professionalism out of health care professionals by allowing the financial people to claim the language. 

By lumping all clinicians into the bucket of “providers”, the payers first tell them that their training, knowledge, education and expertise is merely a set of information “content” that can be replicated, at a much lower cost, by advanced computer systems, by lower level personnel using expert systems, and by technical advances that make their professionalism primitive and even quaint.  The clinicians are told that they must precertify their decisions as the payers don’t really trust how they are applying their knowledge, and must assume that they will be doing the wrong thing for the patient and for society.   The actions of payers and regulators, are based on the assumption that clinicians are likely to make mistakes and to overcharge.  That is hardly a way to incent what we, as patients, appear to want.  Our payment system is now geared towards the false efficiency of having doctors see more patients in less time, and in having more work leveraged to other personnel who are lower cost.  This may actually work against us.  For nurses it is no different.  The skilled nurse of the past, who had a patient who she (and it was usually a “she” in the past) felt personally responsible for has been replaced with the nurse manager who triages the work to the lower cost nurse’s aide and other support personnel.  The interest in knowing the person behind the patient has come to be seen as just too expensive.

 

I admit to being a lover of irony and paradox.  Thus I have spent much of my career designing and building programs that encourage more time to be spent with patients by the people most knowledgeable and proving that the irony rests in the fact that the more expensive, more highly trained people, spending more time, not less, with patients, actually saves money.  Many years ago, I was involved in a program to try and lower the costs of mental health care.  We set up a program, for people who were in a psychiatric crisis.  They were usually in an Emergency Room or in a local police station and we would send a PhD level Clinical Psychologist to the patient, wherever they were, to assess and stay with the patient for however long they needed to.  Patients and psychologists often spent 3 or 4 hours together and then saw each other daily for the next few days.  With this approach, paying the psychologist for their time generously, we saved huge sums of money by avoiding unnecessary mental health hospitalizations, and we saved society from the costs of incarcerating people who were acting out because of their mental health crisis.  We theorized that the time these skilled professionals spent with people in need would easily pay for itself and we proved that.  In follow up studies, we also found that the care rendered was far superior to the usual care as measured by recurrence rates which were a fraction of the usual recurrence rates for this type of population. 

Currently, at Accolade, we have built a system which trains a new type of professional, one we call a Health Assistant, who telephonically stays with people in need, for however long they need: someone who forms relationships in ways that are considered too costly in today’s world.  Yet using that relationship as the backbone of a person’s use of the health care system, improves care and saves money.  The paradox that spending more time supporting, educating, and helping people through the trauma of illness and difficulty saves money is real. 

What does my Accolade experience and my experience with the psychiatric crisis intervention program teach me about incentives for physicians?  It says to me that incentive systems should first respect clinicians and not attempt to get in the way of active patient care.  Programs that require pre-review and pre-approval of treatment are demeaning and ultimately counterproductive.  That includes pre-certification, step therapy, and pre-approval of imaging exams and lab tests.  I do not believe that the decisions by clinicians are always correct, only that the programs that try to ensure that they are always correct are bound to get in the way of the trust between doctor and patient and not encourage the type of joint decision making that is needed.  These “mother may I” programs can have the perverse effect of making access to care more difficult.  We should review a doctor’s patterns and records and pay him or her based on the quality of the care as evidenced in those retrospective reviews as long as the reviews include the clinicians ability to form trust relationships with the patient, and to understand the context of the patient’s life. 

Physicians should be reimbursed in ways that encourage them to spend time getting to know patients, and in ways that encourage a direct deep relationship between the doctor and the patient.  For that reason, in primary care, I look on the movement towards direct contract primary care as a good step towards doctor and patient working together with the doctor being paid to be the trusted advisor.  I also believe the open notes movement (the movement towards a medical record which is truly shared by the patient and the doctor) further encourages the type of trust that this relationship requires and incenting office practices to embrace open notes is likely to have a positive effect.  

My desire to incent proper relationships between doctors and patients makes me a bit nervous about the bundled payment movement as I fear it creates a new administrative barrier to the relationship between a doctor, a nurse and a patient.  The service “bundler” tends to be the health system and they have the most to lose financially when clinicians and patients think carefully about all options and how those options will affect a person’s overall life.

I want the incentives for surgeons and other specialists to include payment for talking to patients, with lower payments gong to those surgeons who see themselves purely as technical experts, doing the procedure and then never seeing the patient again, allowing all follow up care to be done by the physician extender.  I wonder if, for both primary care clinicians, and for specialty physicians, an hourly charge system could ultimately result in more thoughtful consultations and more effective joint decision making and a resultant lowering of costs. 

I expect that we will always need multiple payment and incentive systems that understand the variety of people and cultures in our society.  For some doctors and patients, an integrated system that salaries physicians may be best and for others, a more direct financial relationship between doctor and patient may be best.  Whatever the system, it must properly reward what, Warfield T. Longcope, Professor of Medicine at the Johns Hopkins University School of Medicine once wrote when he stated, “even though a clinician has science, art, and craftsmanship, unless he is intensely interested in human beings, he is not likely to be a good doctor.”  All solutions for paying and incenting physicians must encourage and not discourage the professionalism that leads them to ever increasing interest in the human beings they help on a daily basis.  

Old Doctors in a New a Health Care World

My friend and colleague, Dr Jeff Rubin, will be speaking at the Stanford Medicine X conference on September 7^th. Jeff and I are both in our early 60s, which does look younger and younger to me every day. However, we have both been in health care for well over thirty-five years and during those thirty-five years have been in clinical practice and in the world of care management and building health care systems. So when Jeff takes the podium on September 7^th in Palo Alto, he will be old among the medicine Gen Xers.  In many ways, his message will help remind people that no matter how technology driven medicine is becoming, certain tenets of care must always hold true.

Jeff is a Clinical Psychologist, who in addition to being part of leadership at Accolade, still sees patients one day a week.  He and I and others helped found Accolade in order to use technology to foster relationships rather than to replace relationships. He is appearing before these medical entrepreneurs, many of whom believe that the future of medicine is a future of apps, self service medical protocols, and sophisticated data mining to give a message that says “yes” to those cutting edge tools but only when they are used in the context of a trusting, healing relationship between a health professional and a person in need. He will speak of the danger of believing so much in the tools, that issues of fear, sadness, and social isolation are not given the attention they deserve.

I have been to many such conferences over the past few years and I am always struck by the earnestness and energy of these young people who believe in their solutions’ abilities to solve the ills of our health care system. Many of their creative solutions will contribute a great deal to our health care needs and one can't help but share their enthusiasm when at these meetings. At the same time, people like me and Jeff know that all of these solutions must always be tested against the standard of how they impact the care of an individual in need. They must always be evaluated by how much they help the entire person and the entire family unit. They must understand that while physiology and pathology are the same across people, their experience of illness is dramatically different based on their culture, their family concerns, their finances, their emotional state, and their competing life priorities.

At Accolade, we have developed the new profession of Health Assistant and have used technology to give that patient and their Health Assistant access to the tools needed for them, as a social unit, to make the best decisions in health care. The decisions always rest with the patient and their family based on their values and their beliefs, informed by the best information and supported by the coordination, and the caring of their personal Health Assistant. It works and results in higher satisfaction in health care decisions, better quality of decision making, and lower costs. The technology is important but not as important as the patient-Health Assistant relationship.

I know that the message Jeff gives will be the most important message at the meeting. It will be to use technology as a tool but never to forget the need for a true human to human connection. Patients are people, and they are complex, interesting and different and deserve to be helped in ways that respect the unique aspects of each and every one of them. It takes more than apps, data and protocols to do that well.  It takes caring humanity.