The Relationship Revolution

The Industrial Revolution is dated to the late 1700s, and the early 1800s.  It represented a massive change in manufacturing with society going from hand production to machine production.  This brought with it less poverty and increased living standards for a huge portion of the population.  It did not however go without its challenges as the Luddites of 18^th century England fought the move from skilled artisans to machine production.  The Swing riots in England in the early 1800s fought threshing machines which were starting to transform agriculture just as the Luddites battled against machine production of textiles and other iron goods.  They fought because they saw what was being lost.  The personal relationship that a person had with the farmer, the shoemaker, and the furniture maker who were part of the community was no more.  That relationship and the connection to the source of the food and goods you use on a daily basis was real and brought appreciation and respect that took a back seat to the need for systematization and safety.  At that point in time, that trade off was appropriate and necessary as we brought millions of people out of hunger and poverty. 

While threshing machines started a transformation in agriculture, it was not until after the introduction of the tractor in World War I and the wide acceptance of the tractor (which did not occur until after WWII) and other large agricultural machinery that the family farmer began to fade from view and the industrial farm began its gradual domination over food production. That also brought lower cost food for the masses but even more distance from the local food produced with pride and even love. 

Society has progressed through technology and modern industrial systems.  We are fortunate to have easy access to food through our supermarkets and to clothes, furniture and other manufactured goods through our stores.  We don’t have to trek to the farm, and to the dressmaker, and to the cabinetmaker to buy individual goods.  This progress has freed us from the time and energy needed to access all those goods and services.  It has improved our ability to ensure a basic level of safety and quality in food and manufactured goods.  But it has cost us in terms of local relationships and connection to the people who bring us these goods. 

In many ways, health care has resisted this systematization perhaps due to the intensively personal nature of illness and suffering.  That resistance to systematization has hurt health care in terms of basic safety, minimal quality standards and easy access.  We are now in the midst of an upheaval in health care with an industrialization going on that can radically change health care, in many ways for the better, allowing more access to care and more efficiency in care delivery.  However we risk losing a personalization based on relationships that we have seen lost in manufacturing and in food production.  The lone doctor as an island fighting back disease and answerable to no one but the patient as he or she cares for the sick is somewhat romanticized however it is based on a “hand production” model that is fading from view and that is good!  But that lone doctor had a relationship with the patient that cannot and should not be lost.  The Luddites and the rioters in the Swing riots have, in today’s world been caricatured as those fighting progress however they had a point that a loss was taking place: a loss of human relationships and the pride and quality that goes with those relationships.  When we move to this industrialization of health care, can we maintain the human relationships as we reap the benefits of more consistency in quality and more access to care that the health care industrial revolution will bring? 

At Accolade we are trying to marry the industrialization of health care with a focus on building and maintaining relationships in order to get the best of both worlds.  On a recent trip to Seattle and San Francisco, I saw two other organizations, one in health care and one in food production and delivery that are attempting to do the same.  I believe that Accolade, Qliance and GoodEggs.com all represent a new revolution: the Relationship Revolution that is attempting to bring back the skill and pride of the lone physician, the artisan and the family farmer while retaining and even improving the access to goods and services and the quality assurance that is made available by industrial systems. 

Qliance is a multi-site primary care practice in the Seattle area which employs Internists, Family Physicians and Nurse Practitioners to serve their population.  They describe themselves as a “healthcare organization giving patients affordable access to highly skilled doctors, nurses, and healthcare teams”.  They have the appropriate management systems and computerized medical records to create efficiency and to ensure minimal levels of quality but at the same time they improve relationships between doctor and patient by fostering a sense of ownership by both the care giver and the care receiver.  By having each appointment be a minimum of half an hour, instead of the usual ten to fifteen minutes that is the norm in many practices, and by limiting the panel size of each primary care provider to no more than 800 patients, instead of the usual 2,500 patients in primary care practices, they are able to create a care model for each patient and for each primary care provider that maximizes the value of the primary care/patient link.  This is in contrast to the volume and production norm in most primary care practices that makes real relationships difficult to develop and maintain.  Patients can communicate with their health professional by phone, by email, or in person and receive the same time and attention.  They can reach a group health professional 24 hours a day, 7 days a week.  In the provision of primary care, they are part of this Relationship Revolution. 

Good Eggs is a company started by a group of young idealists, including my son Rob that has grown into a team of more than fifty people in four cities around the country.  Good Eggs mission is to “grow and sustain local food systems worldwide”.  Using industrial and advanced technological techniques, they are bringing locally sourced groceries from local farmers and food makers direct to people’s homes; the groceries are picked and prepped to order.  They are recreating the relationship between the farmer, the bread maker, the local food preparer and other food artisans that occurred when one went directly to a farm to talk to the farmer while picking up fresh food.  Relationships are formed with the producers of this food and the pride and quality that the people who produced your food have is fostered while at the same time the access and quality that is brought about by industrialization and systematization is maintained and improved.

At Accolade, we have created the new profession of Health Assistant.  With health care being so fragmented and requiring the interplay of insurance, regulations, primary care, specialty care, diagnostics, therapies, medical equipment, and other personal and social factors, a professional is needed.  Physicians and medical practices do not have the details and the knowledge of their patient’s disparate financial, insurance and work related factors while a Health Assistance has access to all of these puzzle pieces and the skills and training to coordinate all these factors for people in need.  We have created the profession and the systems to support that person and their Health Assistant as they go through the health system.  We offer the personal relationship that is sorely needed when one is in need of health care help while we foster the consistency, availability and affordability that is the promise of better systematization.  We are on the forefront of the Relationship Revolution. 

Health care will benefit from the industrialization that is now taking place some 200 years after the Industrial Revolution started.  However, in health care, it is even more important to maintain the personal relationships that are inherent in the caring fields of medicine, nursing and other health professions.  This requires a Relationship Revolution as much as it requires an Industrial Revolution.  It is far too easy, in our zeal to create reform, access, and a minimal level of quality to ignore the relationships that underscore each and every health care interaction.  Health professionals have a mission to treat everyone as if they were family, as we also take full advantage of the most up to date information and communication technologies.  This will fulfill the promise of improving care for all of us.  

Culture and Medical Care

It is now 25 years since Lynn Payer wrote “Medicine and Culture: Varieties of Treatment in the United States, England, West Germany and France”.  Published in 1988, Ms. Payer’s book imparts a message that should be repeated frequently.  The message is that medicine is cultural and not only scientific.  Despite the fact that different countries have the same results as measured by mortality rates, the care differs significantly in the types and quantities of drugs used, in the kinds and numbers of operations performed and even in the definitions of what is “within normal limits” and what requires treatment.  She made the observation that these differences in the approach to illness can be explained by differences in culture and values ingrained over hundreds of years. 

Ms. Payer wrote this book while she lived as an American in Paris, working as the health and science reporter for an American newspaper.  She had lived her whole life in the US, having been born in Kansas and had then spent 8 years in Paris working and writing.  Ms. Payer died too soon in 2001 at the age of 56 from breast cancer. 

I find myself picking up and re-reading her book from time to time to get inspired by the simplicity of her message and the profound implications of what she had observed.  So much of medical decision making is cultural and values driven.  Even though medicine has a scientific backbone, the way the science is used by doctors and patients alike, is based on values and trust.  Culture is important because therapeutics must be based on a trust bond between health professional and patient.  That trust bond is built by understanding and communicating values and cultural norms in a way that reflects respect for and autonomy of the person in need.  If you don’t understand and accept the differences of people in the four western democracies that Ms. Payer describes in her book, you cannot understand and accept the differences in people from far more diverse cultures.  In order to be effective in truly touching that person in need and foster healing, a health professional must meet that person on their terms.  That holds true for all cultures around the world and also holds true for differences in cultural norms in different regions of the United States.  It even holds true for different subcultures related to schooling, profession, and socioeconomic status. 

A recent case in point at my company Accolade brought all this to mind.  A young woman from an English speaking country was transferred to the United States by her company.  This brilliant scientist found herself in the exciting yet daunting position of gaining a promotion but also having to move to a new culture.  Language was not an issue however changing cultures can still be quite difficult.  Her Health Assistant at Accolade had been helping her intermittently with understanding her health benefits and her health plan as this was totally foreign to her since her move to the US.  This stress was taken to a new level when she became ill and was admitted to the hospital.  In the hospital, the cultural challenges intensified.  She was told that she had to have a procedure and that without the procedure, treatment could not be initiated.  She then asked what the complication rate of the procedure was and was told that she would do fine, and that the complication rate was only 1 in 100.  As she was in a teaching hospital, the message was given by a doctor in training, a resident, and the doctors appeared to her to change on a daily basis.  She felt alone, frightened, and even in danger.  For a scientist used to working with quality parameters of 1 in 250,000, 1 in 100 seemed barbaric.  She interpreted this as meaning that since a doctor in training, who was not very well trained, was going to do this procedure they expected it to be much riskier than it had to be.  They also told her that she was too sick to be discharged from the hospital and that she either had to have the procedure or just get sicker.  She had no options.

 

She felt like a prisoner.  She felt as though there was no one on her side.  At that point her Accolade Health Assistant®, Kate, was the only person she could turn to.  The patient was speaking to Kate, who she was starting to trust, on a daily basis.  Kate, understood that she did not have all the expertise in that young woman’s cultural background that she needed so she turned to another Accolade employee, Mary, who is not usually on the front lines with people in need, but who came from the same region of the same country as this young woman.  Mary immediately coached Kate on communication norms that would help to build trust. Subsequent phone calls reflected that cultural intelligence in communication.  After a few calls, that trust bond was strengthened in order to help this young woman through her illness. Mary also began to talk with her on the phone creating more trust for the entire team at Accolade.

 

The end result was a patient who felt supported and empowered and who was able to subsequently be transferred to another hospital in order to have a fresh start in building trust with a new medical staff in order to move therapy forward.  It did turn out in the new hospital that the previous well known teaching hospital had been giving her medication in doses that was toxic to her liver.  That toxic effect was reversed and she started to improve. 

I think about all this and wonder if evidence based guidelines which are purely based on science, and not on culture or values, leave out a critical point.  I wonder if the push for productivity that forces doctors and nurses to spend less time finding out the values and cultures of the people in need sitting in front of them will ultimately lead to worse care.  I wonder if we can maintain and even improve our ability to effectively treat people in a way that values them as autonomous independent people when we seem to be pushing in the opposite direction, even with the best of intentions to try to build a more sustainable system from a cost perspective.  Ultimately, medicine is personal with one person touching another in a way that is intimate, honorable, and respectful of all that the person in need is as a fellow human being.  We should accept nothing less as health professionals or as patients. 

The Bystander Effect Revisited

My son’s experience with his recent illness (and he is improving) made me go back to read a perspective article in the New England Journal published in January.  Entitled, “The Bystander Effect in Medical Care” the article retold the story of Kitty Genovese who, in 1964, was brutally murdered while 38 witnesses either saw the attack or heard the victim’s screams.  Following this tragedy, much research went into studying the “bystander effect” which was described as the human tendency to be less likely to help when other people are present.  Those studies found that the diffusion of responsibility is a major element of the effect.  If a large group of people are involved in a process, any one person will assume that the responsibility belongs to someone else or they will assume that action has already been taken.  If you think about this in less urgent matters, you can see this effect when a power outage affects a neighborhood.  Who calls the power company and who assumes that since the entire neighborhood is affected, someone else will call?  That is a common example of the “bystander effect” at work. 

The authors of this article related this effect to limits on resident work hours, the increase in subspecialty care, and the large number of health professionals involved in a patient’s care when they are hospitalized leading to a lack of coordination of care and lack of ownership any one doctor feels for a patient.  I would add in the role of the hospitalist which while potentially improving the quality of hospital care removes the primary care physician from the team.  It is the primary physician who will need to help the person through the transitions from the hospital and back to full health.  They point out the important question that is often not answered, and was not answered in my son’s hospitalization, “Who is my doctor?”  I have to add a question, that being “Who is my patient?”  All too often a contributing factor to the bystander effect is that many doctors see each patient as a disease or the “person in room 225”.    The authors of the article noted that “research also suggest that bystanders are far more likely to intervene when they are friends with one another” and then make the argument that the health professionals have to talk more and integrate more to empower more decision-making.  In other words they need to be friends with each other.  They leave out the crucial aspect of seeing the patient as your friend: seeing the patient as a person in need rather than a grouping of symptoms or a diagnostic dilemma.  Teamwork is great but knowing that Mrs. Smith who is now in the bed in front of you, spent twenty years teaching and had three children and five grandchildren and was seen as a rock to all those who knew her may be much more important.  I suspect that if any of those 38 people who heard the screams of Kitty Genovese knew her personally, they would have been much more likely to act in her defense. 

Dr. Kent Bream in a letter to the editor published in April reacting to the January article wrote that the standards and rules that we now pay strict attention to, while certainly improving care in  many ways, also “ensure a polite, rote production of services” and that “our profession should lead us to favor patients over production”. 

In medicine we are often in the business of finding and treating the uncommon event that can be catastrophic.  That can lead to inefficient production of services.  Health care is only effective (even if potentially less efficient) when we take ownership of the person who sits before us in need.  It is always about the person and not only the pathology.  Understanding the unique needs of the individual and addressing those needs as we would for a friend is a key to proper care.  That prevents the bystander effect. 

I learned that lesson many years ago.  As an intern in Chicago, I was in the Cardiac Care Unit and a writer from Chicago Magazine was there and wrote a piece about the work of that unit.  When it came out, a boxed story told of my caring for a 90 year old man in the unit who was unconscious.  I was quoted as telling the writer that the history was that this man had been sharp and active until the day before this event and was active in his community and with his family.  Therefore the idea of doing less for him than for a younger person was just not right.  I am proud as I look back on that that I knew the person and not just the situation of a 90 year old unconscious man in a cardiac unit and that I, even though I was just an intern, took ownership for the care of that person. 

So this is my call to arms.  Medical professionals and all health care professionals cannot be cogs in a machine.  We cannot be bystanders.  We must be the “friends” to our patients and take action when action is needed rather than assume someone else will do it.  

Lessons Learned at an Academic Medical Center

This past week my child got sick.  It does not matter that he is an adult, on his own, and very capable of caring for himself, he is still my child.  On a Saturday night, he called me and my wife to ask our advice.  He was having vomiting and severe abdominal pain and my old clinical roots in gastroenterology came to the forefront.  “Is the pain radiating? Are you having diarrhea or constipation? What does the vomitus look like?”  After a relatively short time it was clear that this needed hands on evaluation quickly as I suspected that he may need urgent intervention.  I suggested he go to the emergency room.  He lives near an academic medical center and he went there.  In the ER, the triage nurse saw him and determined that he needed to be seen quickly and she sent him back into a room to be seen.  There he sat for more than an hour, writhing in pain with an occasional visit by a nurse to “check on him”.  He and I were communicating via text and by phone and I was trying to stay calm. 

I finally called the ER and asked to speak to the charge nurse.  I asked her why he had not been seen and she proceeded to tell me about all the other, more important issues they were dealing with.  I replied that I understood however with a possible acute abdomen, the protocols are pretty clear: an exam of the abdomen, a CBC to check the white count, an abdominal film and upright to look for free air.  Surely a doctor could examine his abdomen and those immediate tests could be done?  She replied that the tests could only be ordered after he was seen by a doctor and the doctors were too busy. My next call was to the nursing supervisor on call for the hospital.  I explained that I did not understand how someone sick enough to be triaged into a room immediately was not sick enough to have an evaluation begun.  She said she would call me back.  In half an hour she did telling me that the tests I asked about had been ordered along with a CT of the abdomen with contrast.  I spoke to my son who said a doctor had come in to say hello but no one had yet laid a hand on his abdomen, perhaps the most important diagnostic test of all.  

    

After 7 hours in the ER, he was admitted without a diagnosis but with pain severe enough to warrant intravenous morphine.  The ER doctor called and spoke to me at about 3 AM and told me that the   gastroenterology fellow had been notified and would see my son in the morning. 

The next day, my son was no better.  It was about 11 AM and he still had not been seen by the gastroenterologist so I called and paged the GI fellow.  I did get to speak to him and he told me that the floor staff had told him that the admission had been inappropriate and my son did not need to be in the hospital and that he was not planning to see my son.  I asked him why my son was on morphine for pain if he did not need to be in the hospital.  Those two facts were inconsistent. He went to see my son.  I went to get a flight to be at my son’s side.  It was clear at that point that he needed a bodyguard, an advocate, at his bedside. 

    

That evening, when I arrived, my son was in excruciating pain, only relieved by the morphine he was receiving.  I immediately sent an email to the Dean of the Medical School, who is an acknowledged expert on quality of care, to question the quality of care that my son was receiving.  The house staff had decided that he was an "inappropriate admission", either lying, drug seeking, or just someone who was, in the great tradition of medical house staff everywhere, a “crock”.    An hour later the chief of medicine was seeing my son.  His history and physical, consistent with a senior physician overseeing residents and interns, was more thorough than any my son had received since admission.  Usually it is the other way around.   The interns and the residents spend the most time with the patient.  Meanwhile I was trying to figure out who the doctor responsible for my son was.  Between weekend shifts, night floats and hospitalists there appeared to be no one truly taking responsibility for my son’s care.  I learned that the "attending" was a hospitalist who had not examined my son at all.  Nurses stopped in occasionally but were mainly present at their monitors at the nursing stations and as disembodied voices when you pressed a button.  Suddenly, my son developed massive hives all over his body leading to his eyes being swollen shut.  I took pictures with my phone and the night float doctor finally arrived, looking a bit frightened at seeing my son evolve so quickly.  He treated him appropriately and the rest of the night was calm. 

 

The next morning I waited for the rounds.  I thought I would see real deep discussion and thought about my son’s troubling acute illness.  Usually rounds are first thing in the morning and involve a senior doctor, the attending teaching the residents, interns and students all about the diagnosis and treatment of patients.  It traditionally is done first thing in the morning so the plans for the day can proceed seamlessly.  I waited and waited and, while a nice young resident came in and introduced herself about 10 AM, she did not examine my son.  I asked her about the episode the previous evening and she minimized it, until I showed her the pictures which seemed to surprise and perhaps even shock her.  She said that his liver function tests had been elevating and that he was going to have an endoscopy that morning.  My son’s pain had decreased a bit and had localized to over his liver  but his nausea, profound weakness and his joint pain were still troubling.  He no longer required the morphine but was still in a great deal of pain.  I walked out to the nursing station and discovered where rounds were really taking place.  Doctors of all stripes were standing around the computer terminals.   Apparently the computer was the important patient being treated here, not the patient!  The laying of hands on the patient, the communication art of medicine, was just not deemed important.  It hearkened back to an old joke when I was a fellow in the Harvard teaching system that our goal was not cure, but dying a Harvard Death – a death with perfect lab values.    Now it seemed that the new goal was not just perfect lab values but a perfect Electronic Medical Record. 

By now it was noon, the morning endoscopy had not yet happened, my son was being kept NPO (nothing by mouth) and he had not been seen by the attending physician in gastroenterology or the attending physician who was responsible for his care.  I asked again if the nurse could please call down to the endoscopy unit and ask how many cases were ahead of my son.  The nurse called and was told that they were on their way to pick him up.  One hour later they had not yet arrived and I asked again.  They told me that patient transport had to prioritize and my son was not a priority.

They finally took him to endoscopy and the staff prepared him. Another hour passed sitting in the endoscopy unit, not yet in the exam room.  Again I asked about the delay and they said that he was next.  He still had not seen the gastroenterologist.  They eventually took him back to the endoscopy room.   I went with him.  The nurse politely asked me to leave and I politely said that I would not leave.  She brought in the head nurse of the unit who told me that I had to leave.  I explained that I was a gastroenterologist and that my son had not even seen the attending who would be doing the procedure so I would not leave.  She told me that that was against policy.  I asked her to show me the policy in writing and explain the reasoning behind it.  She left.  Shortly thereafter, the chief of medicine, a nice man and obviously a caring physician who was obviously charged with “handling” me came running in (he was already late for something he had to attend) and told me that he had prevented the hospital lawyer from coming in and that he would need to cancel the procedure and that I had caused havoc in the entire medical center.  I calmly said that I was aware that I had asked uncomfortable questions however from a quality of care point of view, I had concerns and also did not know if the endoscopy was indicated or not since he had not been seen by the gastroenterologist.  I told him that I believed the failure to evaluate my son before the procedure to be a breach of quality of care.  He told me to wait a minute and then came running back in with the gastroenterology attending who apologized for not seeing my son and explained that my son’s liver tests had been going up steadily and that it looked most consistent with an acute hepatitis of some sort but that an endoscopy should be done to rule out an ulcer as a cause.   After a brief discussion and my satisfaction that he would not harm my son during the procedure, I left.   

After the endoscopy, which did not find any pathology to explain the pain, the gastroenterologist came out and said that he thought that this was an acute Hepatitis A probably from infected shellfish.   He said that he would discharge my son from the hospital and see him in two days to draw more bloods and to go over the results of the blood tests drawn in the hospital.  That was at 3 PM.  After another long wait for transport, he went back to the room.  By 4 PM, he still had his IV in and had not yet received discharge instructions, the appointment for two days later and his prescriptions. The attending doctor of record, who was a hospitalist, came in to tell my son about the discharge.  She had never examined him during his hospital stay but was the doctor of record “caring” for him.  She left and after another fifteen minutes, I went out to see the nurse, sitting at the computer terminal, who told me that he was working on the discharge.  By 5, I left to catch my plane, after helping my son get dressed with the IV still in.   Shortly after I left, he finally was discharged.  He went to his home, still feeling quite sick, but no longer having the severe pain that had led him to the hospital.  

Two days later, he went back to see the gastroenterologist, who is also a liver specialist, and was told that all his tests had been negative including the test for Hepatitis A but his liver was still showing signs of inflammation with the liver tests being even more elevated.  That, of course, was after waiting an hour past the appointment time to be seen.  The doctor told my son to come back in a couple of weeks for more blood tests and to see him in a month and that he may need a liver biopsy. 

My son still has persistent pain and nausea and it is hard to predict his course without a diagnosis for the injury to his liver.   At the appointment with the gastroenterologist, my son asked for copies of his records so he could discuss, at length, the test results with me and my wife.  The office staff said that they were too busy to make copies. 

That afternoon, I was left to again email the chief of medicine to ask him to put me in touch with the gastroenterologist to obtain the lab tests.  He said that he would forward my email and that the doctor would get back in touch with me quickly.  It has been two days, and it is now the weekend and I have yet to hear from that doctor or see a single lab test result. 

So now my son is faced with inflammation to his liver of unknown cause and of unknown future course.  At the same time, he also processes the lessons he has learned from his interface with the best minds at this academic medical center.   What are those lessons?

• His pain is unimportant.  His pain was discounted again and again by the doctors and nurses
• His time is unimportant.  He was made to wait over and over again, even when he went back as an outpatient, because he was never the high priority and the doctors’ time was deemed more important than his.
• He is assumed to be lying if the “tests” don’t show something definitive.  Until his liver tests went up and the massive hives broke out, he was assumed to be lying, faking, drug seeking or just plain malingering.
• Talking to him, examining him, understanding him as a person and understanding his knowledge and his values is just not important.  Looking at the lab values and reports in the computer and filling in the boxes on the computer screen are important. 
• Feeding him is not important but feeding the computer is crucial.
• His medical records are not his own.  Giving him his records may be a legal requirement but they don’t have to make it easy or quick.  

Are these the lessons we want patients to learn?  Is this what we are teaching our young physicians?

Healer or Master Mechanic: The Future of the Servant Leader Physician

I will be giving Grand Rounds on health reform to an academic department of Obstetrics and Gynecology at a major teaching hospital next week.  The audience will include young physicians in training, eager to learn their new craft and excited about the skills they are developing.  I prepare my slides on the new laws and the forces that now face every practicing doctor and have to wonder whether those young physicians will be trained to be master mechanics of the human body, or holistic physicians treating all aspects of a person.  Will they be leaders of medicine or technical experts of pathophysiology?  For people in the field of Obstetrics, will they see helping a woman bring a new life into this world as a lofty endeavor that is a privilege, or just see the technical difficulties of the high risk pregnancy and the challenging delivery?  Will they be artists, scientists or the traditional combination of both that makes medicine a calling as well as a career. 

In health policy articles, doctors are often described more as expensive resources that must be carefully managed so that they stay focused on diagnosing and treating patients while maintaining productivity than as holistic healers.  Systems to prevent them from straying too far from normative algorithms rather than staying true to the science of evidence based guidelines are described as critical to good care. In that framework, the best physician is one who follows the scientific guidelines most carefully and accurately.   But evidence based guidelines alone do not reflect the context of a patient who may have family problems, financial difficulties and emotional issues that impact the diagnosis and treatment that is the core of the art of medical practice.  Will the guidelines and productivity measures allow young doctors coming up through the system to take the time to get to know their patients in such a way so they understand that context and that person who has the disease (or the pregnancy in the case of Obstetrics)? Will the new career of medicine allow the artistry of medicine to flourish while still maintaining the strong foundation in science? 

The current model for health care is also a team model.  That change from the solitary general practitioner is a strong positive however the risk of a team is that sometimes no one professional takes ownership of the entire patient and the entire situation.  There is no leader.  When we deal in a world of doctors as purely diagnostic and therapeutic specialists we risk the physician focusing on the pathophysiology of the disease and forgetting the entire person in which it resides.  The traditional doctor’s role as the leader of a team falls to the wayside.  The diffusion of the ownership of a relationship can leave a patient feeling abandoned by a complex system that only seems to acknowledge the “science” while letting the whole person fend for his or herself.  The art of getting to know a patient and their family so that the therapy can become a true partnership and a true healing is at risk of being lost. 

There is also an emphasis on a patient’s participation in their own care.  This is also a strong positive as good care should be a partnership.  However much of the writing on patient participation is focused on the patient’s access to Internet based tools and apps and is more about “self-service” medicine than it is about partnership with their health professionals. 

What will I tell these young physicians who are starting their careers and their lives as physicians?  I have to tell them of the challenges ahead.  The challenge of taking time to get to know your patients when you are an expensive resource and you will be judged on your productivity.  The challenge of honing the skills you will need in order to interact with patients as people and not only collections of symptoms.  Those are skills to be learned and practiced over years.  That is why medical training is a hands-on mentoring model that gradually allows the resident in training to take on responsibility in small pieces as they develop those skills.  The skills are not only intellectual but interactive.  Just how do you tell a new mother that the child she has just delivered, following the totally normal pregnancy, has a genetic illness that will eliminate the possibility of watching that child grow to independence?  How does a resident learn to diagnose and treat and also learn how to stay with a person as they are leaving this life with a terminal illness?  On a more mundane level, how does that doctor, or nurse practitioner, help the person with a “minor” self-limited illness who is frightened and struggling to get through the day, convinced that the illness is more significant and more life threatening than the science reveals it to be?  How do we, as a nation, encourage this art through our health policies and teach this art to young physicians and other young health professionals?  How do we teach them the privilege that we have in helping people on a daily basis, using the communication, empathy, and caring arts that we have learned from those who taught us as well as the science that we now focus on in our education?

Traditionally, doctors and other health professionals were trained to be “servant-leaders” and the history of medicine began with a religious framework.  In my religion, Judaism, Maimonides, one of the greatest Jewish thinkers, was a physician and a healer and his code of medical ethics, written in the 12^th century is still used today.  One line of the oath says, "May I never see in the patient anything but a fellow creature in pain."  In Christianity Jesus is traditionally seen as a healer. In Islam, Ishāq ibn ʻAlī al-Ruhāwī wrote in the 9^th century, that physicians must be "guardians of souls and bodies".

The concept of the servant healer which was described in our current era by Robert Greenleaf in 1970 in his landmark essay “The Servant as Leader” is based on religious and philosophical thought.  That concept has been embraced and developed even more by Christian writers who have described Jesus as the model for servant leadership. 

Greenleaf wrote,

"The servant-leader is servant first... Becoming a servant-leader begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first... The difference manifests itself in the care taken by the servant first to make sure that other people's highest priority needs are being served. The best test, and the most difficult to administer, is this: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?"

 Medical training used to stress living with patients, and learning their lives and their experiences in order to better understand what they are going through so as to be a better servant.  Go into any old, established medical center that was founded in the early 1900s and you will see lists of names of doctors and nurses who died from infectious diseases as they fearlessly took care of their patients while living with them in the hospital.  Those people were trained to be servants, artists, and yes even spiritual guides through an illness.  They were taught to be leaders in the best tradition of servant leaders.  Has the arrogance of science removed some of the caring and serving that characterized medicine in the past? 

In the Talmud, in Judaism, there is a passage that says, “The best of the doctors are bound for gehinom (hell)”.   This is baffling however Dr. Daniel Eisenberg of Thomas Jefferson University School of Medicine gives two interpretations.  One explanation is that the physician is always at risk to make a preventable error that would result in death or injury giving them criminal responsibility.  The second explanation is that the physician must be humble and the doctor who sees himself or herself as the “best” may not recognize the need to see himself as an intermediary and a partner in healing rather than the source of healing.  This too, will lead to “gehonim”.

At these Grand Rounds, I need to communicate the choices they will have.  Will they be healers or master mechanics?  Will they take time with patients or be “productive” in diagnosing and treating?  Will they be teammates focusing on their narrow area or servant leaders?  I pose these questions and hope to challenge them to be the servant-leaders, the healers, to continue in the ancient tradition of our craft. How they answer those questions will be up to them.

The Person, Not the Patient

"Who the person is with the illness is usually more important than what illness the person has." Sir William Osler.


A recent article entitled "Patient -Centered Decision Making and Health Care Outcomes, An Observational Study" in the Annals of Internal Medicine by Saul Weiner and his associates at the University of Illinois shows, to quote the article, "Attention to patient needs and circumstances when planning care is associated with improved health care outcomes". Not only does it lead to improved health outcomes but also to lower costs according to another recent article by that same group published in British Medical Journal Quality and Safety. While in Weiner's work there are many implications related to our health care challenges of high costs, difficult access, and variable quality, I also found within the findings of the research a return to the wisdom of William Osler quoted above.

Osler also said, "The good physician treats the disease; the great physician treats the patient who has the disease". Weiner , in his work, has found a way to measure the great physician. He has developed a research tool to determine if the physician (or nurse or other health professional) is trying to find out "who the person is with the illness" rather than only "what illness the person has" in the words of Osler.

Before describing that research tool an old joke bears repeating. A man is walking down the street late at night and sees another man on his hands and knees under a street light. The first man asks the man on his knees, "Are you looking for something?". The man on his knees replies, "I lost my keys" to which the man walking along responds, "Lucky you lost them near this light". The man on his knees says, "I didn't. I lost them about half a block from here". The upright man then asks, "Why are you looking over here?" The man on the ground answers, "Because this is where the light is".

Weiner and his group are not just looking where the light is, which is what many do when they limit research to claims databases and even medical records. Weiner audio records visits between doctors and patients to discover the true interaction and to discover how often the doctor is investigating the context of the person's medical problem. In his research, Weiner has defined ten elements of context and he and his staff listen to these office visits to determine if the doctor has asked about the person's life and values and whether the doctor has tried to find ways to remove the barriers to good care that the life context may have created. The ten elements, or domaines of a patient's context are access to care, social support, competing responsibilities, relationship with health care providers, skills and abilities, emotional state, financial situation, cultural beliefs, spiritual beliefs, and attitude towards illness. The researchers then use a standardized survey instrument, with multiple listeners independently rating the visits, to detemine the number of errors made in eliciting the "context" from a patient and in addressing that life context. Using this technique and survey tool they have shown that understanding the person who has the disease leads to good, and efficient care while just paying attention to the disease itself is hazardous to the patient's health.

One of the more recent studies, published in 2010 found that if a patient had no significant contextual issues, doctors provided appropriate care 73% of the time. If there were contextual issues that were missed then appropriate care was given only 22% of the time. The costs were significant as well, as described in the BMJ Quality and Safety journal article. They found that these contextual errors on average increased the cost per visit by $234. Medical errors in comparison increased the cost an average of $164 per visit. In total, the visits they recorded and assessed for errors by audio recording wasted $174,000 due to the errors while the errors found by chart review alone accounted for $8,700 in waste. Yet the bulk of the work in health policy and in managed care is related to the medical and not the contextual and is based almost entirely on claims review and chart review rather than actual recording of visits.

This leads to another quote by Osler: "Variability is the law of life, and as no two faces are the same, no two bodies are alike, and no two individuals react alike and behave alike under the abnormal condition, which we know as disease." Yet we keep believing that standard medically focused algorithms that hold doctors accountable to do the same thing with each patient are the answer to our health care dilemma of high costs and inconsistent quality. Don't misunderstand. The algorithms and the technology greatly improve the science and are welcome and necessary. However they may have an unintended consequence of worsening the art of treating the individual by focusing too strongly on steps in medical therapy even when the context makes those steps difficult or impossible. Both knoweldge of standard algorithms and of a person's life context are critical to good patient care. Osler understood this and now Weiner has demonstrated Osler's wisdom using experimental methods and scientific techniques.

As Osler also said, "Medicine is a science of uncertainty and an art of probability". Weiner has shown that the individual's values, family, finances, faith, emotions and everything else that makes that person a complex being must enter into both the science and the art for good, efficient care to take place. I doubt that can be accomplished by technology and evidence based algorithms alone. It also requires caring professionals helping people in need. We must either give our doctors and nurses the time, training and tools to "diagnose and treat" the context or develop new professionals, as we at Accolade are doing, to address these individual and population based clinical, financial and human needs.

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Constraints and Healing: The "Triple Aim" Meets the Reality of Illness

The “triple aim” of health care has been present for a long time but that particular term was first voiced by Don Berwick, ThomasNolan and John Whittington in 2008, in an article in Health Affairs.  That triple aim is care, health and cost.  This month’s Health Affairs is dedicated to the “triple aim” going global as more countries around the world struggle to find solutions to the care, health and cost dilemma. 

In the original article in 2008, the authors wrote about the need for three constraints to be put into place to drive us closer to the triple aim.  They were “(1) recognition of a population as the unit of concern, (2) externally supplied policy constraints (such as total budget limit or the requirements that all subgroups be treated equitably), and (3) existence of an “integrator” able to focus and coordinate services to help the population on all three dimensions at once.”  These constraints have societal and population concerns as the focus.  The “integrator” is there to “help the population” rather than to help the person.  I worry about a certain professional arrogance that is inherent when one defines constraints for people rather than asking people as individuals, what they need.  While populations are made up of individuals, individual’s values and views may be minimized when the population is the focus.  When the first step is the development of constraints, the individual is likely to see those constraints as being against their own best interest. 

This focus on the population, as it is currently interpreted, runs the risk of minimizing the need to understand the many human elements in dealing with illness.  It can downplay the fact that the ability of any one person to heal is often as dependent or even more dependent on the social, economic, psychological and spiritual parts of their life as it is on medical science and health system operations.  People need to have some help balancing their life with their illness when they are sick.  People, as individuals need to have a trusted resource to help them through a maze of difficult decisions and difficult choices that poor health demands.  People need help finding their own voice in a system that can appear to be more concerned with population needs than with individual patient care. 

Good health care is labor intensive and the labor is expensive.  Much of that labor is involved in the technical aspects of care but patients and their families also value expert assistance in decision making requiring knowledge and skill that is totally focused on the individual and their own understanding of how they want to live their life and how they value the options before them.   Traditionally physicians and nurses have taken central roles in that communication and decision making.  However our attempts to create efficiencies, as our population grows more diverse and our health system grows even more complex, have caused doctors and nurses to spend less and less time understanding the person as a person, understanding their values and respecting their autonomy.  Doctors and nurses are considered too expensive to be used in such a way.  But that human need is still there and the emphasis on doctor and nurse productivity has led to a void as the time to understand the patients before them as people is not seen as productive.  That void, has led to higher costs as people give in to their fears and isolation and flail around a health care system as they try to find their way to healing. 

An article in the “triple aim” issue of Health Affairs by Michael Macdonnell and Ara Darzi entitled “A Key to Slower Health Spending Growth Worldwide Will Be Unlocking Innovation to Reduce the Labor Intensity of Care” addresses this issue of the cost of expert health labor.  In the United States, 56% of health care costs are labor costs. They point to labor saving technologies, telemedicine services, and the high productivity centers in India at which “the hospital uses expensive assets such as cardiac catheterization laboratories at a rate five times that of US hospitals” to achieve a resultant lowering of the labor costs for each procedure with an efficient assembly line approach.  They speak of the need for more “patient self-service” especially in the management of chronic disease.  They do not address the need to treat the whole person; the need to address the fear, isolation, loss of autonomy, possible loss of job, and possible loss of feeling of personal worth that can easily be a part of any illness. 

We continue to try to find solutions to the triple aim but always appear to focus on the costs and to focus on disease as divorced from life.  Until we truly understand and address the issue of illness from the point of view of the person who is sick and from the family who cares about that person, we will miss the boat. 

At Accolade, the company I have had a part in building, we have addressed the labor economics by addressing individual’s issues of life and illness directly.  We have created a new profession of Health Assistant.  The Health Assistant offers expert decision support and expert knowledge of the whole person and their family to help with all the implications of the illness.  Each Health Assistant maintains a focus on the specific needs of that person and family and helps them from their perspective.  They are serving that person and that family and purposely not focusing on the triple aim goals of the health policy experts.  The irony of this focus is that by maintaining the focus on the person as part of a family and community unit, savings are achieved that are greater than in programs that constrain and greater than in programs that attempt to tell people what is best for them. 

Our new profession is in the business of helping the person find his or her own path to health and healing but not in diagnosing and treating disease.  Our innovation is focused on building a skilled work force to focus on the needs of the individual and the family from their reality and their prospective as they access health care while living their lives.