Complexity for Doctors and Complexity for Patients

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

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

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

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

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

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

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

The Loss of a True "Mensch"

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

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

Paradox and Focus

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

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

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

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

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

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

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

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

Questions, Caring and Competence

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

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

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

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

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

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

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

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

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

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

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

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

Collaboration with Bob Ihrie in Health Affairs

Bob Ihrie and I have just published a blog post on the Health Affairs blog describing the journey that Lowe's has taken in finding ways to better engage their employees and families in health care.  Here is the link

http://healthaffairs.org/blog/2015/02/18/engaging-health-care-consumers-the-lowes-experience/#more-44465

How to Be a Patient: A Cultural Commentary

My wife and I, who are both physicians, are the proud parents of four grown men, none of whom are physicians or have any plans to be physicians.  While we were not able to encourage them towards careers in the health sciences, we have, however, taught them over the years how to be smart patients.  We have taught them, that to be a smart patient requires a combination of confidence, skill and experience and is never as simple as handing yourself over to a doctor or nurse’s care.  A patent must follow four principles:

• Ask Questions: Preferably these questions should be as specific as possible however when one doesn't know the specific questions to ask, any open ended questions are fine.  “Why do you want to order this test?” is an example of an open ended question.  “What is that medication you are prescribing and what is it supposed to accomplish?”  Questions should be focused on the plan of action going forward and how that plan will contribute to good outcomes.
• Remember that You Are the Expert about Yourself: While a doctor and a nurse can talk about pathology and disease, only you know how you feel.  You are the expert on your own values, and your own priorities and that matters when decisions are made about medical care.  No health profession can ever tell you that you do not have a symptom that you are feeling or that your values and beliefs are not important.
• Be respectful but also be demanding.  You are an autonomous individual who deserves to have a say in what is happening to you.  You should never accept an autocratic approach to your care.  You should show respect to the health professionals and demand respect in return.  The doctors and nurses should always solicit your thoughts and opinions and if they do not, you should offer them.  . 
• Have an Assistant: When possible, have a helper with you or available who can also listen and ask questions and help you interpret the answers.  When you are sick, your ability to understand and to make your own decisions may be impaired and someone you trust should be available to help you with that understanding and decision making. 

When you are traveling however, the instructions on how to be a smart patient may be more difficult to carry out.  Medicine is not only about biology, it is also about culture.  What happens when a person is sick and alone in a foreign culture?  The principles I outlined above may be more difficult to use when one is trying to communicate in another language in a place in which the cultural norms are very different.

My youngest son, who is twenty, is now in Prague, Czech Republic doing a semester abroad as a junior in college.  This week, he developed abdominal pain which, over the course of 24 hours, progressed, was associated with diarrhea and finally became severe and localized to the right lower part of the abdomen – the right lower quadrant.  My wife and I spoke to him and advised him to have someone take him to an Emergency Room.  He contacted his program director who gave him instructions to take the bus to the hospital.  In the ER of the hospital in Prague, he was evaluated and told that he needed surgery for presumed appendicitis.
 

Because he is a smart patient, he asked questions.  He knew, from talking to us that diagnostic tests, usually an abdominal CT is part of the standard of care in the United States before someone is operated on for appendicitis so he asked the question of his Czech doctors whether they should obtain a CT scan first.  The answer they gave was that a CT scan would not help and it would not be done.  They made it clear that the question was inappropriate as he should do as he is told.  He was helpless to pursue the conversation and it was clear that the physicians expected him to stay quiet and let them do their work.

Apart from the attitudes and communication between doctors and patients, it is often true that what is standard medically in the US is not standard in other parts of the world.  An article in the journal, Pediatric Radiology in 2009 entitled “Imaging of Acute Appendicitis in Children …EU versus US” written by a group in the Netherlands, talks about this difference in approach to possible appendix surgery and ends with the statement, “Appendectomy should not be undertaken without imaging to confirm the clinical suspicion.”  This article supports the US norm over the European norm.

However my son is in the Czech Republic, part of the EU, and needed care so he was taken to surgery where mesenteric lymphadenitis was found instead of acute appendicitis.  In another European study, written in 2011 and published in the European Journal of Pediatric Surgery, the authors determined that “it is not possible to accurately distinguish acute mesenteric lymphadenitis from acute appendicitis using clinical evaluation alone.”  However due to having fewer CT scanners, and having the medical standard still being that a clinical evaluation alone leads to an appendectomy, my son had unnecessary surgery.  His voice asking for the CT scan was ignored and even may have labeled him as a disruptive patient, or even worse, a disruptive American patient. 

Post-operatively, in the US, we now send people home after a simple appendectomy the day after surgery.  We start feeding people relatively rapidly and have them get out of bed and move around very soon after this type of surgery.  My son, knowing this, asked when he could eat, when he could get out of bed and when he could be discharged to return to his Prague apartment.  These questions were met with confusion, as if the questions were not understood as people in Prague do not usually question their physicians.  The surgical staff would also not talk with me or my wife as they did not understand why a father, even if that father is a physician, in another country would question anything they were doing.  At one point, while on the phone with my son in the hospital and with the doctor in the room, the doctor proceeded to do a procedure on my son while refusing to discuss the need for the procedure or any details about what he was doing.  My son was in a position in which he was hard pressed to advocate for himself and I was equally unable to advocate with people refusing to talk with me. 

The most difficult part of the experience for my son, who is an excellent example of an empowered, smart patient, was the inability to work with the caregivers.  The culture there is hierarchical with the doctors and the nurses telling the patients what to do, and not accepting the questioning that is rapidly becoming the standard in the US system.  In the US, we are starting to take for granted that a commitment to patient centered care, patient engagement and shared decision making is critical for good patient care.  We are experimenting with open notes and more participatory models of care, such as the NUKA system of care and the Accolade model of Health Assistants which encourages patient empowerment. 

In many ways, as we try to find ways in the United States to make healthcare more available and more equitable, other systems of care such as those in Europe are pointed to as examples to learn from.  The European systems of care are seen as more able to create accessible and affordable care for all. 

While we may have a lot to learn from the European systems of healthcare, they also have a lot to learn from the United States especially in improving the communication and working relationship between doctor and patient.  We are learning in the US that better care is rendered when more authority and respect is given to patients as they work their way through the healthcare system.  This is a learning that should be spread throughout the world.  

The Purpose of the Annual Physical

We know, through the good graces of the US Preventive Services Task Force that the annual physical exam does not lead to less disease and does not lower mortality.  Specific elements of those exams are helpful, such as screening for hypertension in everyone and screening for breast cancer in women over 50 (and perhaps over 40).  With this in mind, Dr. Ezekiel Emanuel, started the New Year with an opinion piece in the New York Times admonishing us to “Skip Your Annual Physical.”  In it he writes,

“We all make resolutions and promises to live healthier and better lives, to make the world a better place.  Not having my annual physical is one small way I can help reduce health care costs – and save myself time, worry and a worthless exam.” 

But maybe it just isn’t that simple.  Later in the article he does note that, “the exam provides an opportunity to talk and reaffirm the physician-patient relationship even if there is no specific complaint.”  He goes on to also confirm that he will get his yearly flu shot and his routine colonoscopy.  I would also be remiss if I did not point out that Dr. Emanuel is also the author of the article in The Atlantic entitled, “Why I Hope to Die at 75” in which he points out that “creativity, originality and productivity are pretty much gone for the vast, vast majority of us.” 

Let me offer an alternative view of the annual physical with the proviso that I acknowledge that I do not hope to die at 75.  I want to live and contribute with the wisdom I accumulate and want to have a relationship with a health care professional, who will help me maximize my years even if I am not as sharp as I once was. 

The key element that I want to maintain is the relationship with a health professional who can know me, as a person over time.  In our complex health care world, the idea that a person can wait until they are sick and then have the knowledge and skill to access the right healthcare for that need is naïve.  It is not realistic to think that a person can effectively access and use the healthcare system without an advisor or helper who knows them as a person, and not only as a disease.  Whether the health care professional is a physician, a nurse or a new professional remains to be seen, although I suspect the model will have more possibilities than our current primary care physician approach.  The problem is that disease and illness is complex and has social and psychological elements that require a knowledge of the entire person – a knowledge that often only comes over time and with the building of trust between the professional and the person in need. 

In a blog post in Forbes, Ron Smythe writes about applying complexity theory to healthcare.  He states,

“Human biology therefore, is indeed complex, but it is much less complex than the work done by a health care delivery system.  What’s the difference?  Why do we struggle to achieve our goals in clinical outcomes, safety and financial performance in these institutions chock full of brilliant, well-intended people?

The difference is those people….they introduce social factors into the processes and structures of health care delivery, along with emotional states and varying levels of competence and performance – all of which can have an incredible impact on results.  This is compounded by inefficient information sharing and decisions being made, at times, distant from the action.”

I worry that if we merely admonish people not to have annual physical exams, without giving them another way to have an ally in the healthcare system should they need care, we are merely creating a new problem of people flailing around the health care system, not knowing what to do.  There is still a need for a health professional who knows a person as a person, including their social and psychological issues.  This is still needed to help a person obtain the care that is right for them when they are ill, and we all get ill at some point. 

So the annual physical may not be scientifically needed, however there remains a need to have a relationship with a health professional that can get to know you over time – a health professional who can help access the right care at the right time and who knows your social and psychological issues.  At Accolade, we believe that a team approach with a professional Health Assistant as the relationship manager is one way to ensure that someone knows the patient as a person over time, and can help them access the care they need.  When this is combined with a medical home system, with a primary nurse practitioner or a primary care physician being the team member to perform the proper physical exams at the proper time, a better system of ongoing care can emerge. 

We now have Health Assistants who have had five year relationships with their clients, getting to know them and their families, knowing their social issues and the psychological hot buttons and helping them get the care they need efficiently and effectively.  We know it helps people get the most out of care delivery and saves money for both the system and those individuals.  It does not preclude the need for a caregiver to also know the patient however it assists the relationship aspects of care in an era of episodic sick care (instead of screening physicals), short appointments, and fragmented care.     

The driving force behind a yearly exam is often fostering a relationship between a single health professional and a person.  As our society moves away from this “yearly physical” model, the Health Assistant, or a similar professional, may have to move in to fill the relationship void left by this societal change.    The yearly physical exam may go the way of other non-scientific modalities but the access gained by having a knowledgeable person assisting you through the system must remain.