My Pet Peeve

Everyone has something that just bothers them and causes their teeth to chatter and chills to go up their back: something that elicits the same sort of visceral reaction as fingernails on a chalkboard (although I know I date myself with that metaphor in this day of white boards and markers). For me, that pet peeve is when someone, especially someone in a caring profession, says, “There is nothing I can do.”



That simple statement signifies giving up, abandonment and an attitude that fails to recognize the infinite options and the infinite good that is possible when people who care keep trying. Some may see this as being unusual as I am the same person who wrote in a previous blog “Don’t just do something, stand there!” But when you stand with someone and you support a person through tough times, you are doing something and you are doing something extremely important.



A book I just read entitled “Nine Lives” written by Dan Baum also makes an aspect of “doing something” come to life. In this oral history of nine people’s lives in New Orleans before during and immediately after the Hurricane Katrina disaster, one of those people, Wil, relates the story of his father’s illness and time in the hospital. His father, Da, a larger than life figure who was Wil’s model for being a pillar of strength and dignity, was in the hospital with cancer and had massive bleeding from his rectum. Wil seeks out the doctors caring for his father and is told, “Your father is dying right now.” “We could put a shunt…but that wouldn’t change anything. We got men in here that can survive…We got to look after them first.” Wil goes back into the room and his father says, “They told you I was going to die.” His father, Da then goes on, “You go home to that new pretty wife of yours and get some sleep. I’m going to call you in the morning. We’re going to get them to give me that surgery.” Early in the morning while it was still dark, the phone rings and Wil lets it ring thinking that is the hospital saying that his father has died. He finally answers and hears, “I told you I was going to call you in the morning,” Da’s voice said. “You thought it was them people calling to say I was gone, didn’t you?” “They’re about to take me down to surgery.” Da was someone who knew how to be strong and fight for himself as an individual. Caring professionals can and should help people be strong and fight even if there is supposedly “nothing” that we can do.



Doctors, nurses and other health professionals are often faced with examples of problems that do not have any apparent solution. In those cases there is still something that can be done. Just giving someone their own voice, helping them find their strength, giving them options (and there are always options even if all of the options are not very good) and helping them marshal the resources they need to cope with their situation no matter the medical prognosis of that situation is “doing something”.



This type of problem is commonly seen with people who suffer from chronic pain. A recent article from the latest issue of the American Journal of Medicine illustrates this through a description of the lived experience of pain. Using the poetry of Emily Dickinson, which may seem unusual in a scientific peer reviewed medical journal, the author emphasizes the experience of living with pain. He states: “Chronic pain sufferers typically report experiences of isolation and alienation from their physicians and providers, from their caregivers, and even from their own bodies.” The author closes the article by stating “the healer can assist the pain sufferer in the reconstitution of his or her world, one in which pain is still present but does not entirely blank out the colors of the pain sufferers existence.” So it is for health professionals and those in caring roles in which “doing something” often means helping the person cope with a medical issue or other issues which have no concrete solution but have solutions to the alienation and isolation that accompanies them.



I hear the phrase, “There is nothing we can do” and hear an attitude of negativity and capitulation. The complacency and cavalier attitude that can easily overcome us is reflected in that simple statement. Those in need are all unique people and we are helping them when they do not know where else to turn. That is our job and our mission. We have to think of each individual and always find a way to do something to help them in their own journey no matter how difficult and “hopeless” it is. There is always hope when there is caring.

A New Accolade for Accolade

This week, Inc. Magazine announced their fastest growing companies for 2012 and Accolade was at the top of the list for health care companies.  While this is a great accomplishment I cannot help but see it as just the beginning; the beginning of a great company and of a new profession.  Speaking personally, the effort of starting this company has been the culmination of my entire career.  For years before our start, I spoke out about the need to help people not manage disease in managed care and spoke about the need to have people when sick be recognized for their unique situations and attributes and have their care customized on that basis.  While it knowledge of evidence based practice is critical, it must be used as a core element and not as a limiting factor of care.   

At this point in the growth of Accolade we have proved that you can take that customized approach that includes not only scientific medicine but the unique dynamics of each and every family, and actually spend less money overall than if you just used a standardized, one size fits all approach.  We have learned a lot along the way and realize that we are just beginning to move Accolade and the profession of Health Assistant being recognized as a needed resource in our health care world of complexity.

We have learned that in order to come this far you need:

·         Investors and a Board of Directors who understand that it takes time and money to build a company that truly improve people’s lives and create value that can be reflected in revenues.  We have such a Board and more.  We have a Board that understands that the building of an Accolade is really about improving the world and not only building a company.

·         A  leader who can put all the pieces in place and create a culture that supports a truly unique and new way of doing business and who questions all old assumptions in the building of a new approach, a new profession and a new company. 

·         A group of people, all of whom understand the fundamental principles we work under, to design all the different elements, from the training to the IT systems, to the operational systems, to the support materials to even the designs of the office spaces that all support the culture and the values of helping people. 

·         Very strong IT systems, operational systems and support personnel to make this work.  Health Assistants cannot work in a vacuum and are only affective if they have the proper tools and the proper information in place when they need it. 

·         Most importantly you need a group of individuals to actually do the work of caring, of supporting, of understanding and of helping those in need.  Our Health Assistants, whatever their initial backgrounds and degrees  all have come together to build something that is great and that has a profound impact on those we help and on those we will help in the future. 

In addition, other major lessons learned and some of the reasons it has taken five years to come this far building an approach that makes so much sense and is so successful in both helping and lowering health care costs are:

• Changing a paradigm is extremely difficult.  When you build something new, that does not fit nicely into preconceived notions, it is hard for others to understand.
• Creating simplicity for individuals and employers is extremely complex
• You need forward thinking, creative people leading the employers who work with you.  We are fortunate to have that in Comcast, Medtronic and now Lowe's

What we have done thus far is not for the faint hearted.  It is hard and it requires a blend of extremely different talents and knowledge.  

The movement towards building the profession of Health Assistant also addresses in a positive and productive way the complexity that is inherent in a health care system that must take human behavior into account and that must have the knowledge of all aspects of care which includes the clinical/scientific, the financial, the emotional, the social and the religious elements.  When one is sick, it is a family affair that affects every part of every person who is in that family unit.  The profession of Health Assistant recognizes those pieces and helps the patient and the family through all of it.  The professional Health Assistant also helps someone regardless of whether they are critically ill or merely in need of reliable advice about staying healthy and everything in between.  Meeting people where they are and not just trying to cherry pick those people who are spending large sums of money or who happen to be using the health care system at a point of time creates the right relationships to make a real difference across a large population. 

I can only hope that as Accolade continues to grow that we will see more and more people recognize how affordable care depends on a customized patient by patient approach and that approach can be simplified for all concerned by having Health Assistants for every person in this country and possibly the world.  If that seems overly ambitious think again.  We at Accolade know that we can help people as individuals make their own decisions and create a better health care system at the same time. 

What Patients Want

It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.
William Osler

Recently, in the New England Journal of Medicine (NEJM), there were two articles that gave different points of view on how to reform health care in order to decrease costs in the wake of the continuing discussion about the Affordable Care Act (ACA).  The two articles both had identical short introductions by the editors of the journal that read, in part, “There is wide agreement that we must find ways to bend the health care cost curve.  Taking different approaches, the two articles that follow present a range of options, including reducing both the prices and quantity of services for public and private payers, reducing administrative costs, implementing new market based incentives and reforming the tax subsidy for employer sponsored heat insurance.”

I was struck as I read both articles and reviewed the ideas that both contained that they shared a common focus.  Both articles looked at patients and their families as consumers and focused on the financial incentives and the financial barriers to receiving quality health care and both framed the discussion strictly in terms of cost, legislation, and administration.  Both addressed patients as consumers, rather than as people who are frightened, depressed, and concerned about their own frailty and the effects of their disease on others around them.   In both defense and deference to the authors, (and they hardly need my defense), they are all people who care deeply about patients in a holistic way and were specifically commenting on aspects of health policy and not on patient care.   

However, I do believe that when addressing health policy, you have to think about individual people in need or the policies developed can easily have unintended negative consequences for those who are faced with using the health care system in all of its glory, cost and confusion.  Tom Lee understands that as evidenced in an article in that same journal published one month earlier.  His article entitled “Care Redesign– A Path Forward for Providers” did not focus on the national issues of decreasing cost and instead focused on how people obtain care.  Early in the paper he states, “…healthcare is intended to help people, not just provide a commodity as inexpensively as possible”.    Now this was something I could relate to!

Much of Lee’s article gives a primer on asking patients what is important to them, which is unfortunately quite a radical principle.   We at Accolade founded our company upon this simple philosophy of listening to the patient and addressing their concerns first.  Lee’s stated goal in care redesign is, “to improve the value of care as defined according to the patients’ perspectives”.  In order to do this he states “we must understand the outcomes that matter to patients and families and what it costs to achieve them”. 

Most physicians and health care organizations believe that they know what people want and it appears obvious – they want to get better and they want to spend as little money as possible doing so.  However that misses the point that as you delve into detailed discussions with people you often find out that what they want as an outcome actually deviates in the details from the physicians’ assumptions.  For example, in Tom Lee’s article he described a study of stroke patients.  He states, “From interviews with patients, we learned that many of them are interested less in readmission rates than in the number of days spent at home during the first 90 days after a stroke.”  The Stroke team that did these interviews, also came to understand that “we know how to measure readmission rates but not yet how to measure what matters more to our patients” and also came to understand “we don’t reliably capture information regarding other outcomes, such as continence and mobility, that are important to patients who have had a stroke”. 

More than five years ago, when we were just starting to design Accolade, we understood that to be successful in helping people and lowering costs, we had to understand what people across the health care spectrum wanted as outcomes, including those who were healthy and those trying to stay healthy, those who were acutely ill, those with chronic illness and those with catastrophic, life threatening illness.  We talked to them and to this day our model of caring continues to depend on talking to individuals continuously to find out what they want and what outcome is important to them.  One of our lessons is that as illness progresses and enters new stages of recovery or chronicity people’s desired outcomes change as well.  Asking people at one point in time is important but even more important is having a relationship with them that allows for that constant discussion as people’s priorities change. 

Lee states in the article that “An emerging insight is that our overall organization has to function more like our most beloved clinicians – showing patients that we care by asking them how they are doing and by responding accordingly, even when were not fact to face with them.”   It is important we follow Lee and Osler’s wisdom, understanding every “sort of person” who has a disease and always “asking them how they are doing and responding accordingly”.   

A Normal Day at Accolade: The Accolade Olympics

Health care is a team sport which, when done well, appears as elegant and seamless as watching the Dream Team at the Olympics.  It is a sport that combines the talents of many skilled professionals while also including the caring amateurs who are closest to the patient.  I have a chance every day to watch and take part in this team sport as part of the Accolade Olympics.  The nice part of this is these Olympics are normal days rather than once every four year events surrounded by pageantry. 

Recently, I expanded my chance to observe our teams at work.  It was almost by chance that I accomplished this and it involved something as mundane as changing my office.  But to understand this change, first you have to define what an office is as my office is a riddle.  The riddle goes, “When is an office small but large, central but peripheral, alone but surrounded by people, and on different floors in a building and even in different buildings?”  The answer is when the office is actually a standing desk on wheels that can be parked anywhere in the office.  I have used a standing desk for a long time,  mainly for health and comfort reasons, however I recently switched to a standing desk on wheels that I can take and park anywhere.    Now that Accolade is in more than one location, I even have similar “offices” in both of our locations.  I have found that this allows me to spend time working in different parts of the company from one day to the next and even from one hour to the next if I like.  So now I get to spend time with more of some of the neatest people in the world, the people who work as Health Assistants for the clients of Accolade and who are part of the daily Accolade Olympics. 

On a recent day while I was working at one site, I had a wonderful microcosm of an ordinary extraordinary day for an Accolade team.  I got to see Don in action, talking at length to someone with a mental health issue that had never been addressed, watching him as he paced and talked and gained the trust of that person on the phone who needed help desperately in order to create an entry into a needed visit to a therapist.  He was masterful with the only challenge being not walking into me as I also pace while on the phone working in my “office”. 

I got to listen in as Michael spoke to a doctor’s office, advocating for a client to have the office furnish a pre-certification form to the Health Plan so that a needed service could move forward and be reimbursed.  While one may think this would be simple in this instance it was not with the office showing very little desire to cooperate.  Michael, by being firm, professional, forceful and friendly all at the same time, made it happen.  It was as beautiful to watch as a 9 from the judges during the diving competition. 

I saw Dana and Marya, teaming up beautifully to help someone with a medical problem that had medical issues that needed a Clinical Health Assistant like Marya and the trust, calming and expertise in logistical and health plan related issues from a professional Health Assistant like Dana.  Both Dana and Marya made real connections with this client and you could sense the trust and calming effect both had on that person as you listened to the tag team formed by that dynamic duo.  The two person woman’s volleyball competition did not see coordination and teamwork as strong as that. 

I saw Jamie working way past her scheduled time to leave wanting to make sure that her client’s needs were totally addressed with a sense of ownership of those needs that I could only sit back and watch in awe.  No tennis match going long into the night as the match point was elusive had as dedicated a competitor as Jamie.

And I saw Curt coaching this herd of independent but team oriented professionals do their job as a Olympic coach would.  He was giving Michael positive feedback about the last client he helped while also exhorting Jamie to leave in order to take care of herself, letting her know that her own health and wellbeing was important in order for her to take care of those clients.

 

All this time, I was working “in” my office, on the phone and on the computer, working as a team with Melissa, a Clinical Health Assistant, Bob, a pharmacist and with the clinician at the Pharmacy Benefits Manager as well as with our Employer to address a pharmacy policy that had unintended consequences for a number of clients.  That extended team was able to adjust that policy so as to maintain the quality of clinical decision making while also improving the policy so that the unexpected consequences would not occur again.  I was working with Colleen, another Clinical Health Assistant who was helping a client with a problem that was extremely serious and urgent in nature as he was in danger of losing his leg due to circulation problems and his vascular surgeon was away.  The surgeon who was present was not being helpful but by working with the clinical leadership of the hospital and building them into the team for this issue, we were able to get this man the care he needed provided by a different surgeon and possibly save his leg. 

In other words, this was a normal day for a normal team at Accolade that play the team sport of health in a way that Olympians would envy.  I have the wonderful fun and honor of being an occasional coach for our teams while also being a team member when needed for the broader staff and the communities we serve.  Most of all I am a fan of our dedicated Health Assistants who help so many people on a daily basis.  I love my job, my new office and especially the caring Olympic level professionals who are part of the Accolade team.

The Secret to Losing Weight

 I know the secrets of medicine.  Back in medical school, during an initiation ritual, in the darkness in a room lit only by candles, those secrets were shared with me.  I have been sharing them with selected others for many years, after receiving their solemn oath to use such powerful information with only seriousness of purpose and gratitude towards those who first were given this knowledge by the elders of medicine (no I am not talking about the editors of the New England Journal of Medicine.  They are among those who try to keep it secret which, if you read it regularly you understand.)  My only goal is to clear the mist and shine a light on these secrets.  My ultimate goal is to open medicine to the public as it is too important to be left only to doctors.  Rob Spiro’s (for total clarity I admit he is my son) article in the Huffington Post and the recent pilot launch of his company Good Eggs, has inspired me to start revealing these secrets to a wider audience through my blog (so that both of you who read it can also know them) and to start with a topic that is related to nutrition and eating.  I start with the secret to losing weight. 

Good Eggs and their approach to fostering locally produced food reminded me that the secret to losing weight is as much about how you eat, as it is about what you eat.  Because, the best, safest, healthiest way to lost weight is (a drum roll please) 

EAT LESS AND EXERCISE MORE

I understand that some of you may be underwhelmed by this secret however it is much more profound than you may think.  By changing how you think about food, by actually thinking in terms of the quality of the eating experience and the quality of the food you eat, it is extremely easy to eat less.    While our culture encourages a “more is better” supersized attitude, the fact is that food tastes better when eaten slowly, when savored and when appreciated in a deeper almost spiritual manner.  When you eat that way, you tend to eat healthier foods and to eat less. 

In most religions, food has a spiritual place.  In Judaism, which I practice, there are specific prayers to be said before eating or drinking anything, the gist of those prayers being to thank God for the food.  When these prayers were written, you ate food after you or someone you knew actually produced it.  It was highly personal and part of the social fabric in which you lived.  It was only natural to thank God for all that went into what was before you on the table as it was readily apparent that the food did not just appear and that you and others you loved worked hard to put it on the table.   In today’s world, we have moved towards anonymity of the food producers.  We just go to the supermarket and ignore the work, sweat and pride that people who produce that food take.  We sometimes cannot even recognize the food as food as it is so processed and packaged that it becomes a product rather than something that came from the earth or from an animal that was slaughtered (hopefully humanely as both kashrut in Judaism and halal in Islam encourage) so that you can thrive.  However, when you stop before each meal and take a moment to think about all that when into the food, and thank either God or the people who produced it, or even the food itself as some have suggested, you actually eat slower, eat less and naturally follow a major aspect of the secret of weight loss. 

This attitude towards food also can force you to never eat on the run, eat standing up, or eat in a car, all of which can lead to eating more and gaining weight or maintaining higher weight.  That rushed approach to eating can never acknowledge all that goes into the production of the food and can often be based on eating products which are made to be eaten in that manner rather than eating food.  The approach of food as something to be slowly savored leads to less eating and more weight loss.  In our world, food research historically has been rightfully focused on feeding more people at less cost.  In other words the research has been focused on quantity which from a world hunger prospective makes perfect sense.  Local food in contrast is often developed for quality rather than quantity with local food producers focused on organic farming methods, taste and nutritional value rather than cost and quantity. 

Thus how you eat becomes even more important than what you eat as long as you are eating, as MichaelPollan has wisely stated, food rather than packaged items that you cannot recognize as food.  When you purchase food that is locally produced, since it does not need the same additives to increase product longevity as food created at a distance needs, you know and can easily recognize it as food.  As natural flavors are brought alive you don’t need the flavor that comes from the added sugars and other artificial flavors that processed foods bring to you and that can lead to weight gain.  When that first bite is savored, you often want to eat more slowly as you actually taste every bite.  Do this and you do eat less. 

Exercising more is also part of the secret.  This should also be done as a part of your life and not as a sprint to a finish line of less weight.  Just move more than you currently move and work up from there.  Start by parking further away in the parking lot, taking stairs instead of elevators for one or two (maybe even three or four) floors, pacing while talking on the phone instead of sitting.  From there, find something you like doing and dedicate time to yourself to do it.  Create your own escapes and small strategies to move more and let your activity increase from there.  One of the other parts of this secret is that the more you move, the less hungry you will be.  There should never be a finish line, although you may have goals along the way.  I believe the goals should not revolve around your weight.  They should revolve about changing your life and the way you approach food and activity as part of your life. 

Your goals should focus on ways to permanently make yourself happier.  None of these secrets involve a “diet” or a Biggest Loser approach to training that most people with work, family and other obligations will never have the time for.  Instead it is all a way of giving more time to your own needs as part of your everyday life: making this approach a part of living, not a part of dieting. 

I will now admit that I did not always follow my own secret as stress and time worked to undermine my own knowledge.  But I am now doing this, and have lost almost thirty pounds and feel infinitely healthier and happier.  It may be hard to change, but when the main change is just to pay attention to your own real needs in terms of food and activity, it feeds (pun intended) on itself and just gets easier and easier.  That too is part of the secret. 

Physicians, Ethics and Costs

Physicians, Ethics and Costs

A thoughtful article in this week’s New England Journal ofMedicine entitled “Centsand Sensitivity — Teaching Physicians to Think about Costs” by Lisa Rosenbaum, M.D., and Daniela Lamas, M.D. is an interesting perspective on the culture of medicine which rewards and emphasizes, completeness of evaluation weighed against the societal need to lower costs.  They ask the important question,

“Is there a place for principles of cost-effectiveness in medical education? Or does introducing cost into our discussions threaten to destroy what remains of the patient–physician relationship?”

Their answer is that cost should play a role however the examples they give make it clear that the costs to the individual are the important factor and not necessarily the societal costs.  They quote Dr. Martin Samuels of Boston’s Brigham and Women’s Hospital as stating:  “when physicians start weighing society’s needs as well as those of individual patients, they begin to lose the essence of what it means to be a doctor. When we lose our personal responsibility to individual patients, he says, ‘We are in deep trouble.’”

It is important to understand just what is being discussed and in many ways, I strongly agree with the statement by Arthur Caplan that they site, “The fight about cost is a smokescreen,” says Caplan. “What’s really at issue is the definition of ethical physician advocacy.” 

Health professionals who care about patients need to care about the person and not only the patient.  Caring about a person means understanding them as an individual and not only as an organism with a disease.  A person’s economic health is a part of their personhood just as is their psychological health, their family connections, their spiritual health and their work.  Cost is an important factor to many people but it is not necessarily more important than the other pieces that make each of us unique. 

The article does understand that the cost to the individual is the important consideration finishing with the statement,

“Now some educational reformers are offering us an added ethical incentive.  Put simply, helping a patient become well enough to climb the stairs to his apartment is meaningless if our care leaves him unable to afford that apartment. Protecting our patients from financial ruin is fundamental to doing no harm.”

Just to emphasize the point.  A health professional caring for a person should always think about the costs to that individual, financial and otherwise and should never think about the cost to society when it conflicts with the good of the individual.  That is the true essence of being a care giver and is the true essence of being a Health Assistant.  Of course the irony of that ethical imperative is when you act in that manner, focusing on the needs of the individual, the result is that the costs to society as a whole are decreased significantly.  That is also the strong lesson that we at Accolade have learned.  

Good Healthcare is a Symphony

Good health care is like a fine symphony.  Different professionals and different skills must work in concert to create a result that is much bigger than the individual components.    Here are two versions of a well-known anecdote in the classical music world that has been repeated in many versions over the years.  It tells the story of an efficiency expert enlisted to investigate a symphony orchestra.

Version 1

 He reported: "I found hidden unemployment. At least seven employees played the very same movements, on violins, throughout an entire piece.  On the other hand, the employees in the wind and percussion sections sat through extended periods of a concert without moving a muscle or playing a thing. I also discovered there were entire parts that musicians played over and over, for no reason.  Most of the employees appear to be unskilled as the management has to employ a man, full-time, to wave his arms around and signal to them what to play, when to stop, at what speed, and even at what volume.”

All of this, forced the efficiency expert to come to the conclusion an orchestra is a wasteful institution; it is neither efficient nor profitable; its output may be categorized as "arty and impractical".

Version 2 – A specific report on Schubert’s Unfinished Symphony

1. For a considerable period, the oboe players had nothing to do. Their number should be reduced and their work spread over the whole orchestra, avoiding peaks of inactivity.
2. All 12 violins were playing identical notes. This seems to be unneeded duplication, and the staff of this section should be cut. If a volume of sound is really required, this could be accomplished with the use of an amplifier.
3. Much effort was involved in playing the 16th notes. This appears to be an excessive refinement, and it is recommended that all notes be rounded up to the nearest 8th note. If this were done, it would be possible to use para-professionals instead of experienced musicians.
4. No useful purpose is served by repeating with horns the passage that has already been handled by strings. If all such redundant passages were eliminated then the concert could be reduced from two hours to twenty minutes.
5. The symphony had two movements. If Mr. Schubert didn't achieve his musical goals by the end of the first movement, then he should have stopped there.

In light of the above, one can only conclude that had Mr. Schubert given attention to these matters, he probably would have had time to finish the symphony.

Why do I relate these stories in a discussion of health care?  

In many ways, the move to managed care has been told by these anecdotes.  In the move to make health care more affordable, which is a wonderful goal as it increases access to health care, we have tried to make individual doctor visits more efficient and we have succeeded.  Unfortunately, much of the richness of the physician leading a team and coordinating an effort with the goal of creating a wonderful result greater than the individual pieces has been lost in the process.  As physicians are not rewarded for coordination and in many ways are even discouraged financially from working together the doctors become nothing more than technical experts in their own scientific fields.  Even family physicians who are supposed to be the paradigms of ongoing coordinated care, are unable to do all that needs to be done to assist, coordinate and support those traveling through the complex medical system.  Instead they are expected and trained to see large numbers of patients per day with “simple” illnesses and to triage those who are sicker to specialists. 

But in our complex medical world, there are no simple illnesses.  Every illness has emotional, financial, and social factors.  The mother with small children and limited income who has asthma and needs a chest x-ray and pulmonary function tests needs to understand how to pay any copayments and be able to afford those co-payments, needs a way to schedule the tests, needs a person to watch her children while she goes for the test, and needs help understanding the risks and benefits of the medications that she will have to purchase and take.  She needs someone to help her find the way to communicate all this to her family, who depend on her, and needs help dealing with the stress and fear that accompanies it.  Yet we now have no concert master or conductor.  The primary care doctor has no time, and is not paid to do all this.

I am enough of a traditionalist to believe that a good physician should make the best “conductor” of this symphony although I also know that strong health professionals trained in other disciplines such as nursing, psychology and social work can also play that type of role. It is less a matter of formal degrees and more a matter of communication and coordination skills and resources.  In the best of all possible worlds, a doctor would team with a professional communicator/coordinator/supporter (in Accolade terms a Health Assistant) to give the patient the best chance of having health care that resonates as a fine symphony.  A doctor would then be able to still be relatively efficient while giving the patient everything he or she needs. 

We need both scientific medicine and a symphony like beauty and elegance in the delivery of that medicine.  Until that happens, managed care, of which I am a part, will capture efficiency at the expense of truly caring for those in need.  Here at Accolade, we are committed to providing the humanity that everyone needs in a way that creates cost savings while enhancing the important element of caring.