Challenging Paradigms: Practicing at the Top of Your License

The industrial revolution has come to healthcare.  Old paradigms – from routine physicals to even the concept of the doctor as the captain of the ship – are being challenged as we try to find more efficient ways to deliver high quality care.  However as fast as we break down the rigidity of past practices in order to foster better systemization we seem to build new paradigms that may have negative unforeseen consequences.  These new “truths” can rapidly be set in concrete while the problems they create are given little attention.  We must always be asking ourselves whether we are truly improving care or if we are merely swinging the perennial pendulum of change too far as we try to reject shibboleths of the past. 

A new paradigm that I see in many realms of medicine is the concept of having each professional practicing at the top of their license and their training.  What that means is that a doctor should not do something that a nurse practitioner can do; a nurse practitioner should not do something that a nurse can do, and a nurse should not do something that a nurse’s aide should do. In practice this concept has manifested in a variety of ways.  During my recent hospital stay which I described in a different blog post, the nurses rarely touched me or even saw me as they stayed at the nurse’s station monitoring my cardiac rhythm, watching my trends on the computer, and only coming in to give me medications twice a day.  The nurses’ aides took my vital signs, helped me get to the bathroom and changed my bedding.  The doctors did not come in at all as they were able to access the record from multiple locations and I only saw the physician at the time of my procedure.  In psychiatry, this same concept has developed to the point at which it is unusual for a psychiatrist to engage a patient in talk therapy and instead is involved mainly in medication management with talk therapy being performed by licensed therapists who are not MDs.  For surgeons, it means that they are often focused totally on their work in the operating room with nurse practitioners assessing the patients and caring for them before and after the surgery.

The fact is that this type of approach has some attractive features.  For the system, it could potentially save money.  For the health professional, it frees them from doing tasks that they may not like to perform and allows them to focus on the tasks they are trained to do. But is this better for the patient?  Is this strict division of labor really conducive to high quality, patient centered care?   

In some ways, this new paradigm is related to the industrial revolution that health care is now undergoing.  The assembly line was a key component of the industrial revolution of the nineteenth century and the movement towards a new industrial revolution in health care can be seen to be following that tried and true formula.  A true division of labor approach in which everyone limits their practices to the top of their license and training has advantages.  Assembly lines allow for specialization of roles and that often leads to less variability which is associated with higher quality products being produced at a significantly lower cost.  The cost of labor goes down as each person involved only performs a small number of tasks.  That allows for training requirements to be narrowly focused as well, with the jobs themselves then more easily filled at a lower salary level.  If more can be done by nurses’ aides who are lower paid than nurses, the theory goes that nurses can focus more on the “important” nursing roles which results in a decrease of total costs and a more effective and efficient system. 

However the disadvantage of the assembly line is that unique craftsmanship is lost.  From the worker’s point of view, the work becomes repetitive and the “big picture” of the ultimate goal, complete with individual pride of reaching that goal is lost.  The individual ownership of the product (and in health care the product is the well-being of the patient) risks being lost in a system that is based on assembly line principles.  There is a reason that the finest products in the world are often not made on an assembly line but are made by master craftsman who take great pride in their work.  We see some of these disadvantages in this new medical paradigm as physicians and nurses are rewarded for how well they do their individual tasks rather than how well they treat the whole person.   

Medicine is filled with the risk of low probability and high consequence events, some of which are due to our treatments and not only to the underlying disease.  Quality medical care demands anticipating and avoiding those events and treating people in such a way as to minimize the risk of any intervention.  That may require more holistic thinking about the patient rather than task based thinking.  A health professional who is very hands-on even if that is “below” their training and license may be the best defense against poor quality care.  A recent article in ProPublica that focuses on surgery risks and patient safety makes this point when they describe two surgeons in a small community hospital in northwest Alabama who are among the best in the country at doing joint replacements.  Dr. Aaron Joiner and Dr. John Young have performed 282 knee and hip replacements over the last five years with zero complications.  The way they accomplish this is the antithesis of practicing at the top of your license.  As described in the article, they often operate together even though that hurts their income.  They believe that having two surgeons in the operating room provides a backup and an immediate quality control.  They describe a typical interaction in the OR as one in which they are open and honest when they see their partner doing something that does not measure up to their own standards.  “I may look at something a little backwards or get turned around,” Joiner said.  “It’s nice for one of your partners to say, ‘What the hell you doing?  You’re not out huntin’ this morning.  You’re doing a knee replacement!”  They also do all the post up care themselves rather than having physician assistants or nurse practitioners do that for them.  As Dr. Joiner puts it, “We don’t cut corners.  We do it the right way every time.” 

I remember when I was training in gastroenterology, serving on the service of Dr. William Silen, a giant in the world of surgery, who was also a dedicated teacher, mentor and patient advocate.  At Harvard Medical School, the William Silen Lifetime Achievement in Mentoring Award honors his leadership and his memory.  We would make our rounds with Dr. Silen to see patients at 5 AM every morning and at 6 PM every evening, personally seeing each patient pre and post operatively twice a day with our operating room duties in between.  The fellow or resident who just wrote an order without actually seeing the patient, talking to the patient, and examining the patient would not last long with Dr. Silen.  The doctor in training who thought that removing a naso-gastric tube or changing an intravenous line was a nurse’s job and not his or her direct responsibility would quickly learn that attitude was not acceptable.  For Doctor Silen every task that involve caring for a patient was in the physicians scope of practice and was, by definition practicing at the top of their training and license because medicine was about ownership of the entire patient – their problems, their hopes and their lives – not about the specific task that needed to be done.

The idea that all health professionals practice at the top of their training and license when used in the context of a true team all sharing full accountability for a patient can help both quality of care and the human caring that patients need.  However it is very easy for that pendulum to slip past the midpoint into the realm of assembly line care that focuses on the immediate task rather than the entire patient and their family.  In an age of ever expanding health systems, employed physicians, corporate medicine, government medicine, and large mega-health benefits companies, it is far too easy to focus on an assembly line mentality rather than a team mentality that can truly improve care.  Let’s not allow the new paradigm that demands division of labor to ever divert us from the idea that all care for a fellow human being in need is by definition at the top of one’s training and license.  

My Recent Hospital Stay: Getting the Joke

I was home following my hospital stay, trying to modify my lifestyle and attempting to adjust to new medication to help me deal with my angina (chest pain due to heart disease) when the 5 page letter, using words that only a lawyer could love, came from the health plan. 

“We have reviewed information received about your care and specific circumstances using the MCG criteria for Inpatient and Surgical Care. Based on this review, coverage for the requested admission is denied.” 

Happily I did not take the denial letter seriously.  If I had I would have been at risk for readmission to the hospital with more chest pain and shortness of breath.  My first reaction was to think this was extremely funny.  I know how these issues work, and also know that my diagnosis of unstable angina (increasing chest pain related to heart disease while on medication) with an abnormal stress treadmill test fit criteria for coronary angiography, an invasive procedure to see my coronary arteries.  I had, indeed already received health plan “approval” for the cardiac procedure.  I also knew that the best practice algorithm from the American College of Cardiology, for unstable angina called for “admission to the hospital for bed rest with continuous telemetry monitoring.”  All that had happened correctly.   I assumed that somewhere along the line, despite more attention being given to documentation than to actually doing anything (see my last blog post), something had been lost in translation.  My cardiologist, a very exacting person when it came to do a cardiac procedure was perhaps less exacting when it came to filling out the paperwork.  The hospital department that submitted the documentation may have missed the boat in communicating what was really happening in my life when I was forced to enter the hospital – a step I loathed taking. 

But then I stepped back.  What if I had received that letter and did not have the knowledge I had?  Would I believe that my doctor did something wrong or did not treat me correctly?  Would I curse my health plan and accuse them of being uncaring and incompetent?  Would the anxiety of potentially getting a huge bill I could not afford create more stress when I was trying to deal with the stress of having ongoing heart disease?  And would I believe that MCG criteria were some magical code that determined whether I would live or die? 

My knowledge of the facts made me see the humor in this and not be stressed by the game of telephone that occurs when physicians and hospitals try to communicate medical needs to the health plans.   I knew that MCG stood for the Milliman Care Guidelines first developed by an old friend, Richard (Dick) Doyle who was a brilliant physician and consultant when he worked for Milliman, a respected actuarial consulting firm.  I used to joke that the first generation of the Milliman guidelines were made up by Dick Doyle with his feet up as he looked over the Pacific Ocean in his house in San Diego rather than by any scientific method.  It felt like the use of only the initials, in the denial letter, made these guidelines have so much more weight than they really were meant to have – making their use in the denial letter almost comical.    Milliman Care Guidelines are used by many health plans and even by government plans to judge efficiency because of their operational ease, not because of their scientific rigor.  They are not meant to be nuanced and rather are guides to what can be achieved in the perfect world that those who practice clinical medicine rarely see.  My cardiologist, who admitted me and did the coronary angiogram, was well trained, smart and caring and did everything right clinically.  The people in the health plan were all caring professionals trying to uphold the plan requirements in a fair way.  All these people are good people doing the right thing and yet the letter that was sent to me seemed to say that my care had been wrong and would not be paid by the health plan.  It was communicated to me, the patient, in a heavy-handed way that said that what I had done was “not medically necessary” according to those magical guidelines. 

Upon further investigation, I discovered that the contract that the health plan has with this hospital calls for these admissions for unstable angina to be billed as observation unit days, rather than admissions.  I was lying in a bed in a room as an inpatient and this contracting fiction that drives payment was meaningless both to me and to the hospital staff who cared for me (or who cared for the computer as I speak about in my previous blog).  I, as the patient, will be held harmless and not have to pay for this purported mistaken admission driven by my acquiescence to supposed “sub-standard” care since the mistake did not occur and the denial was just due to the financial relationship between the health plan and the hospital. Now that my investigation is done, which I took on as a form of entertainment, I will go back to focusing on my own health issues. 

The good news is that my cardiac procedure did not show any critical lesions but instead showed disease that is readily managed by lifestyle modification and proper medication.  I am also fortunate to appreciate the irony of the whole episode.  I get the inside joke that others may not.  My goal is for everyone to have someone at their side who also gets the joke and who is able to understand health care and health benefits.   That person – in my world the Accolade Health Assistant – knows how to navigate the system and help people through the decisions, the documentation, and even the denials when they come.  I don’t want anyone with heart disease or any other medical issue to be at risk for new medical problems due to “payment fear” related to accessing health care just because they don’t have my knowledge.  Everyone needs a health assistant and with the experience gained from this medical interlude, I will continue my efforts to make that happen. 

My Recent Hospital Stay and the Care of the Computer

This did happen but should not be seen as disparaging the nurses and doctors who were responsible for my care.  They performed my procedure efficiently and skillfully.  Those health professionals are just working in a healthcare system undergoing dramatic change legislatively, financially, technically and even socially.  That is difficult for all concerned – doctors, nurses, and patients.  As we proceed with these changes, and with making better use of computer systems and electronic media in medicine, we must never lose the human aspects of caring. 

I was recently discharged from the hospital after suffering an acute problem that required an invasive procedure. For those of you worried about depersonalization of medical and nursing care I want to reassure you.  The commitment to caring for the computer is front and center.  The nurse and the doctor are diligent in paying attention to the computer, frequently touching the computer to show concern, and feeding it frequently.  But it is not only the computer being cared for.  The checklists are all being filled in.  The population health data repository is being enriched whether or not the data is accurate or needed for the individual patient care.  That makes the regulators and the health policy experts (and admittedly I may be considered to be one) happy.  That means that we will have data to study, and to ponder and to drive new regulations and policies.  I am excited to know that the databases that are produced by the questions that are asked will be robust. 

As the patient, I felt better as the nurse sat across the room from me in front of the computer terminal, asking me questions that sometimes had little relationship to me or the reason that I was in the hospital.  It was good for the population health database.  The bright, young nurse had been well trained and touched the computer frequently to show her concern.  When something had to be done that required touching me, the patient, she carefully, and with great concern, called in the nurse’s aide to do such tasks such as take my vital signs so that her concentration on the computer checklist was not diverted.  That also allowed for the principle of practicing at the top of your license to be fulfilled.  I felt happy and secure that all documentation was in order and that all procedures were followed to the letter.  I knew that she was helping the hospital capture all the needed information for payment and that the system would be better for the reimbursement being done properly.  I knew that the Joint Commission, which accredits hospitals, would give this particular hospital a high mark for having followed process and documented in a rigorous way. When she asked me, as it was the next question on the list, what my goal was for the day, and I told her that it was to survive until the next day, she dutifully recorded it and even got up from the computer terminal to write it on the whiteboard for all to see. 

When it came time to prep me for the procedure, which required washing and shaving certain areas of my body that were to be the focus of the procedure, she carefully and thoughtfully again called the nurse’s aide to get that done. The nurse’s aide asked me in turn if I would do it myself and even if I had a razor as they had moved floors and could not find it on that floor.  Her concern for my sensitivity at being touched was striking and the annoyance that she showed as I told her that I would rather that she prepped me was only to show her concern for invading my space.  The entire time, I knew that the nurse was at the monitoring station in the center of the floor and was able to watch for any abnormalities of my heart.  I felt safe and cared for.  When the monitor alarms went off and no one came, I could just push the buttons and I knew the caring voice of a nurse would be projected into my room saying soothingly, “can I help you?” in order to make me feel as though she was in the room with me.  That was always followed by a message that she would get someone into my room as soon as they were available.  It made me feel less afraid.

The entire time I never did see my doctor, except at the time of the procedure, however I knew that he could access the electronic medical record from anywhere in order to make his day and night more efficient.  I felt good knowing that he really did not have to see me or talk to me at all but that he was in charge and on top of all of my care.  I knew that having him say hello before I was sedated was enough to have trust that all of my concerns and fears were being addressed. 

So be reassured: Caring for the computer, filling the database, and driving efficiency remains the focus of medical care today.  As a patient, that should make you all sleep well at night.  

The Gift

Last week I had the privilege of spending a day with a group of physicians who transcend the science of medicine and are true practitioners of the healing arts.  They are people who recognize that the role of health care goes beyond the treatment of disease and is about the healing of people beyond the disease they present with.  The Accolade Medical Advisory Board consists of Dr. Larry Kaiser, Dr. Saul Wiener, Dr. Ivor Horn, Dr. Adam Perlman, Dr. Samuel Hammerman, Dr. Andrew Lasher and Dr. Joe Betancourt and they were together for a discussion of ways patient care can be improved and ways Accolade can continue to contribute to that improvement.  They are all leaders in medicine and their biographies can be found here.  The day was exciting because it focused on ways to improve the care of people in ways that address the differences in people rather than the commonality of disease.  The discussion concerned a person’s life and experience with the healthcare system.  Most exciting was the consensus that this humanistic approach to medicine holds within it the key to the dual goals of improving the quality of medical care and lowering costs in order to make care more accessible.  All of these leading physicians have the gift. 

So just what is the gift? The ability to internalize that the trust given you by your patients is sacred. This means seeing each patient as a unique person, one with their own life, their own reactions to disease, and their own values. Indeed it means seeing not 'patients' but people: professors, shopkeepers, clergy, salesmen, fathers, grandmothers, all as complex individuals with their own worlds of families and friends who they love and who love them. An older patient who, on the surface, presents as weak and confused, must be seen back to his younger self, as one who has lived a full life of many experiences. A young adult struggling with chronic liver disease must be seen as a person on the cusp of a career, a family, and hope for a full life. All doctors are trained to see pathologies. The best doctors, the ones with the gift, are trained to see the human beings behind those pathologies: people struggling to rise above the challenges of life, including those who sometimes succumb to those challenges. Each physician who has this gift had wonderful teachers who passed this gift on to them.

During my years of training, the clinical professors who gave their time for the pure love of medicine and of patients were the core of teaching how to relate to patients and understand them as people. It is a difficult gift to learn.  Dr. Shunichi Nakagawa in the journal JAMA Internal Medicine talks about going from being a surgeon to a specialist in palliative care.   He found it was even more difficult to learn the communication skills than it was to learn surgical skills.  “Although a conversation looked so easy and seemed so logical when my mentor started it, when I tried for myself, I became stuck at each step – the exact same feeling I had had during surgery.  What is the difference?  How could I get better? How could I be like him?  My time was limited; the palliative care fellowship lasts only a year.”  It was and is difficult to maintain that gift as well because the emotional toll can easily lead physicians and nurses to focus more on the mechanics of disease rather than risk internalizing the emotional trauma that they feel with their patients.  I had a conversation recently with Dr. Chip Rice, a nationally known expert in intensive care and currently the President of the Uniformed Services University of the Armed Forces.  He said that there are very few grey heads working in the Intensive Care Unit.  All of the doctors tend to be young because the trauma of dealing with so many people who are critically ill and who die, can lead one to leave that environment.  Those who stay can suffer the risk of focusing only on the mechanics of the unit, the ventilators, the perfusion drips, the computers, and the like and lose the humanity.  In his just published book, “On the Move”, Dr. Oliver Sacks speaks movingly of this gift.  He states, “I felt it my business, my responsibility, to enquire about every aspect of their lives.”  He speaks of one of his teachers who “taught me about paying attention listening to what lies beyond the consciousness of words.” 

I started the meeting of our Medical Advisory Board meeting this past week with those words from Dr. Sacks because they spoke to the shared beliefs of those people who sat around the conference table.  While I sometimes worry that the gift is at risk of being lost in a medical world of doctors focusing on the computer and the app rather than the patient, the people at that table who discussed the importance of a person’s culture, the importance of their life context, and the effect that socioeconomic status has on health care reminded me that the great teachers still exist.    With people like Chip Rice teaching our military physicians, and people like Larry Kaiser at Temple Medical School, Joe Betancourt at Harvard, Ivor Horn at the University of Washington, and Saul Wiener at the University of Illinois teaching medical students across the country, I know that despite our movement towards potentially impersonal computerized care, the clinicians are still teaching the humanity of caring for others along with the pathophysiology of disease.  They are staying true to the Oath of Maimonides, an oath now recited by the graduates of many medical schools which states, “May I never see in the patient anything but a fellow creature in pain.”  The next generation of physicians has a very difficult medical world ahead of them as we go through a computer revolution in healthcare and an ongoing political firestorm however they still have the great teachers and role models and that does reassure me.  

Doing Everything Right

A few weeks have passed since my kidney stone attack and my visit to an Emergency Room.  Time brings healing and perspective: it brings the ability to reflect on the experience and to hopefully gain new insights.  The time since my suffering this “minor” medical bump in the road has given me a chance to think about how everything can be done right, while feeling wrong. 

When I teach, I often share my definition of a minor illness as an illness someone else has.  Everything I or someone I love has is major.  My point is that when we treat people who are suffering, we must put ourselves in their shoes and try to understand what they feel and how those feelings impact their lives.  We must see the situation through their eyes, understanding their story and their perception and not only their pathology.  Indeed a minor illness that impacts one’s ability to work and one’s ability to meet responsibilities can be very major to the person in need of care. 

I suffered my first kidney stone attack in 1977 when I was an intern.  I ended up needing surgery (minor surgery but major to me) to remove the stone.  Through the years, I have had episodic attacks of kidney stones, especially when I allow my water intake to fall down.  I force myself to drink water in order to keep free of stones and the renal colic that ensues.  I do everything right but the stones still occasionally  occur. 

My latest kidney stone attack began with the all too familiar severe cramping pain in the left side of my abdomen radiating to my flank.  As is often the case with my kidney stone attacks, it was accompanied by a shutdown of my intestines.  A common complication of kidney stones is that the normal peristalsis, or motion, of the intestines stops.  This is called Adynamic Ileus or Ileus and the resulting obstipation (defined as intractable constipation), bloating, nausea, vomiting and total abdominal pain that comes with it can be more distressing than the severe cramping stone pain. 

For the next two days, I drank as much water as I could, avoided food as my intestines were just not working, and watched my urine for signs that the stone might pass.  While the cramping pain was only occasionally severe, the obstipation, bloating and nausea were especially troubling.  The entire time, however, I was confident that this was another bout of kidney stones and the stone would eventually pass.  By the second day, the pain, obstipation, bloating, and nausea were getting worse and had me doubled over. I made my way to the Emergency Room when the pain and the severe obstipation became unbearable. 

I presented at the front desk, immediately telling the clerk that I was in severe pain and needed a specimen jar as I needed to use the restroom.  A sense of urinary urgency often accompanies kidney stones and I knew that a urine sample would be needed.  My sense of pain and my symptom of urinary urgency were not matched by the ER clerk’s attitude or speed of response.  I waited patiently and after about ten minutes had the specimen jar in hand and was able to use the restroom.  The ER clerk did everything right but it didn’t feel right to me, the patient. 

After about twenty minutes in the empty waiting room, I was taken back into a room in the ER where the nurse started an intravenous line, drew blood, and took my vital signs.  I was then seen by the nurse practitioner.  He took one look at my extremely distended, tight abdomen and became energized as he thought that I had an intestinal obstruction or a perforation.  He asked me if I wanted an evaluation for obstruction or perforation. At that point, while I was relatively certain that I had an Ileus and not an intestinal obstruction I believed that it was good to make sure that the more urgent problems were not present.  I also believed that I was in no shape to be my own clinician.  The necessary tests were done to ensure that I had not perforated part of my bowel, while we waited for the blood and urine tests to return.  The nurse practitioner was doing everything right.

When the labs came back, the results showed that my kidney function was impaired, a surprising result which, while possible with a kidney stone and with some degree of dehydration, was a bit worrisome.  Meanwhile, I was receiving intravenous fluids to counter any dehydration I may have had from my limited intake over the previous two days.  The nurse practitioner was asking my opinion for every decision often in an open ended manner.  What pain medications I wanted, what test I wanted done, how best to proceed were all asked at each step.  He was following a model of patient involvement and shared decision making: doing everything right.  The problem was that at that point I did not really want to be asked which pain medication I wanted or exactly what I wanted my diagnostic evaluation to be.  I just wanted the correct pain medication for my situation and the clinician’s expert judgment to assess and treat me.  While I am a true believer in shared decision making, that was not necessarily the right time to use it.  I was in pain, I was distended, and my bowels were functionally if not mechanically obstructed.  I was not necessarily thinking all that clearly.  The nurse practitioner was being respectful of my status as a physician which was the right thing to do….but possibly at the wrong time. 

With the lab results in hand, I was able to have my CT scan but without the contrast usually used to better delineate a stone.  In the face of renal impairment, contrast infusion can be dangerous.  The CT scan showed a small stone present, and also showed distention of my intestines consistent with an Ileus with no signs of obstruction or perforation.  With that result, all of the activity and interest in me as a patient came to an abrupt halt.  In the eyes of the nurse practitioner and the ER nurses, I was no longer a real emergency.  The door to my room was closed, I did not see much of my nurse practitioner and the alarms on the IV monitor, and the BP monitor seemed to go off regularly with impunity unless I pressed the button to call someone in.  All of this was consistent with the norms of emergency medicine.  The “true” emergency, mechanical bowel obstruction or perforation was “ruled out” in medical parlance so they saw their job as done. However from my perspective, I was still suffering.  I still had the stone, was still in pain, still had severe abdominal distention and obstipation with Ileus and had known renal function impairment.  But all interest in me had stopped since, in the eyes of the staff, I was no longer an emergency.  They were doing everything right. 

I had received about 2 liters of fluid and wondered, with some presumed dehydration, whether I should receive another liter as eating and drinking was still difficult, but the staff at the ER would have none of it.  I did not have a “surgical abdomen” so they wanted me out of their emergency room.  I was discharged and I left.  Two days later, on Monday, I was able to see my personal physician and my urologist and received the medication and counsel I needed.

In the following two days, my pain, obstipation and distention continued as did my difficulty eating. After the third day of drinking as much water as my nausea would allow, my stone passed, my ileus and resultant obstipation cleared up, and I was back to work.  A CT scan two weeks later, and repeat lab data showed that the stone, the kidney impairment and the ileus were gone. 

There are those who would say that the care I received in the Emergency Room was perfect for the function they are charged with performing.  They gave me hydration, they diagnosed the problem, they “ruled out” a different problem that would have meant urgent intervention and they sent me on my way.  They paid strict attention to the medical facts and protocols.    

But I want more.  In an emergency situation and in an emergency room, while it is important to be in the moment, the truly great physician, or nurse practitioner should also think past the moment and see the situation through the eyes of the patient.  The ongoing uncertainty, fear and pain should be addressed even if addressing those concerns is a purely human and not medical science endeavor.  They must think and plan for the day after the ER visit and not only what happens within those four walls.  If all they do is everything right in the moment, they have become technicians and not the healers that our health professionals should be.  

Death is Inevitable but Fear and Loneliness Need Not Be: What Medicine Learns from the Humanities

Often the best way to understand health care is through fiction, religion and philosophy.  Ultimately, health care should improve the human condition and not only treat the biological elements of disease and pathology.  One can learn more about the human condition from stories as told in literature, in faith, and in philosophy than from research that is published in medical journals even as the medical journals enlighten the science behind disease diagnosis and treatment. As Andrew Solomon, in his review of Oliver Sachs new memoir, “On The Move”, writes in the New York Times Book Review, “Medicine is dominated by the quants.  We learn about human health from facts and facts are measurable.  A disease is present or not present.”   That is the current state which he calls, “arithmetical naiveté.” He describes Sachs career in contrast as being devoted to the “unfathomable complexity of human lives” and quotes from Sachs new book (which I must confess I have not yet read however I have read all his other books) “All sorts of generalizations are made possible by dealing with populations but one needs the concrete, the particular, the personal, too.”

   

My thoughts about medicine this week were triggered by an article from, of all sources, the on-line magazine, “Outside.”  The article entitled, “My Dad Tried to Kill Me with an Alligator” is a story of a father doing something that appears irrational and stupid.  In this true story, Harrison Scott Key’s father has him and his brother jump out of their boat to dive down to find a lost fishing rod and reel in a bayou filled with alligators.  That has the effect of helping his sons, especially his somewhat overweight, bookish son overcome fear and understand, in the words of the author that “safety should not be the defining virtue of a life.”  Analogously, while safety should not be the virtue of a life, addressing the biology of disease to avoid death should not be the only virtue of treating people who are ill.  While avoiding death is a virtue it is not the only virtue and for some, may not even be the most important at a particular stage of life. 

Yet in today’s medical world we seem to approach all health risk and all illness as being removed from the elements of life that may make life worth living.  Mass media suggests that science has an answer for everything and that taking a certain pill, or enrolling in the right diet or exercise program will make all your health problems melt away, the implication being that illness and death are optional.  Science, according to the medical reports on the news and the commercials we watch will have your believe that we can live forever and avoid or easily cure all illness.  They don’t acknowledge the reality that the wonder of living inherently involves taking chances and making autonomous choices in a complex world full of uncertainty. 

As physicians and health professionals, we know the reality of disease however we fall into the trap of believing that a person’s biology is the most important element of their life when in reality, it often is rather low on the list, even in the face of devastating illness.  The most important elements of life for most people are related to the values they have, the social environment in which they live and the people they care about.  When we ignore the complexity of the human condition, and when we focus on the medical only, and not the joy of life, then we lose the ability to help our patients truly heal. 

Interestingly enough, the “quants” can even show this with data.  For example when you study why people are readmitted to the hospital, it is related to their lives more often than it is related to their disease.  Living alone is the number one risk factor for being readmitted to the hospital in those over 65 according to a recent study in the Journal of the American Geriatrics Society.  That is not something you can see on a pathology slide but it is part of a person’s story.  Another review compiled research on the marriage health connection.  Married people are healthier than unmarried people and have lower health care costs.  Interestingly enough this is despite the fact that they have more obesity which some point to as the root of all health care cost problems. 

We see this understood quite well in the 23^rd psalm, The Lord is My Shepherd, perhaps the most famous of all the psalms.   In Harold Kushner’s book interpreting the 23rd psalm, he speaks of the protagonist as being someone in despair.  Rabbi Kushner writes, “The psalmist cried out to God and this miracle occurred.  The miracle was not that the man’s fortune was reversed, but that he was not alone.”  Thus the data on readmissions and the one chapter of the bible that many in the English speaking world seem to know by heart give the same message – that being alone worsens the pain and despair that illness can initiate and that by having someone at one’s side, healing is more likely  to occur.  As Harold Kushner states it, “God’s promise is not that we will be safe but that we will never be alone…We will hurt but we will heal.”  While having a spouse by one’s side is a bit different than having God by your side, the point of loneliness being associated with poor outcomes when in a time of stress was well known before the scientific quantitative studies were done and was even published!  (This relates to a joke told by Israeli academicians asking whether God could get tenure at an Israeli university.  The answer is “no” because he only had one publication and it was not in English.)   

None of this is to suggest that the medical aspects of care are unimportant, only that the human elements are just as important as the medical.  Thus the humanities, as our window to the human condition are important in the understanding and treatment of people who are ill.  Just as Harrison Scott Key writes of facing up to and overcoming fear and the 23^rd Psalm talks of God as helping us not feel alone, we as health professionals have to find ways to help us understand people with all their complexity and make health care into something more than purely scientific ways to avoid the inevitability of death. 

Grieving the Loss of Trust

We come here today to memorialize a time when medical care was based on a sacred trust.  This is a celebration of a concept so basic to care that for centuries, trust was the only aspect of medical care.  Before the advent of modern medicine, the sacred trust between a physician and a patient, and the physician’s knowledge and experience with helping a person through the illness journey was all there was.  There were no imaging exams and lab tests to make a diagnosis.  There were no effective surgeries, antibiotics and other modern medicines.  There was only the physician, laying on hands, able to predict the course of an illness, and staying with a person through their suffering. 

    

An article this week in Bloomberg Business Week reported on the increasing tendency of consumers to order their own blood tests.  While I am a staunch advocate of patient autonomy and of shared decision making, and believe that consumers should be able to order their own tests, as a physician I wonder why anyone would want to do so.  Lab tests are most useful when they are ordered for a specific purpose, understood by both doctor and patient, and when the results are openly discussed by a patient and a health professional.  I, as a physician, never order my own tests even though I understand how they are used and what they mean.  I trust my physician to work with me to order tests and to interpret the results together.  The objective, caring perspective of my physician is critical to me as I decide what to do about my ailments.  I suspect that this trend towards self-service medicine is a symptom of a larger malady – that being a loss of the trust that once defined medical care. 

At one time, the relationship that you had with your doctor and your nurse was seen as sacred.  You opened yourself up in every way, physically and emotionally to your health professional and believed that they would help you and have your best interest at heart in everything they did.  You truly bared your soul as well as your body in the hope that the physician would help you survive – even thrive – with the fragile vessel that is the human body.

 

But today, physicians are told that they must not have their total focus on you, the patient, but also on the population.  They are taught that they must adhere to the bio-medical rigidity in specific care paths and be efficient while doing so, rather than address the unique values and hopes of the individual they are treating.  Patients are told that they must take responsibility for their own care, must embrace self-service and use apps and the Internet instead of a trusted professional, all for their own safety and the greater societal good.   No wonder the trust is dying. 

Michael Millenson wrote a blog post this week entitled, “Parsing Patient Engagement: Better Compliance or Better Decisions?”  Michael is an expert on quality of care and rightly notes that quality care is not about technology but about how that technology is used in order to transform the health care experience.  He wrote, “Transformation in the doctor-patient relationship must recognize the importance of the medical evidence, the patient’s preferences and values and the doctor’s clinical experience.”  It is hard to see that in self-service lab tests. 

 A client at Accolade, my company which uses technology to put human relationships first, had a bad experience with a primary care physician.  The Health Assistant, who is that client’s trusted resource, came to me for help.  The client and his wife had seen a new primary care physician and believed that the physician had over-tested them for financial gain.  I reviewed the claims and found that all the ordered tests were consistent with a first new patient visit.  I then spoke to the Health Assistant and suggested that the real problem was that they did not trust this physician.  Upon further discussion with the Health Assistant who knew the client as a person, I learned that the client and his wife were relatively new to the United States, having emigrated from India.  The husband spoke heavily accented English and the wife spoke very little English.  The primary language in their household was Hindi.  We then found them a new primary care physician who was Indian-American and who spoke Hindi.  They loved and trusted their new doctor and no issue of testing for financial gain came up again. 

The sacred trust in health care is the secret ingredient that allows care to be effective.  The loss of trust that I see saddens me but also leads me to action.  For trust hopefully is not dead.  It is on life support but we can work to make it central to medical care once again.  To again quote Michael Millenson’s blog post, “clinicians—with a persistent nudge from patients and payers – will have to lead the transformation themselves.”  I include in the term clinicians, the professional Accolade Health Assistants, and all health professionals, not only physicians.  We must all lead the effort to ensure that trust remains a central element in all of our health care.  Without the trust, all of the apps, new tests and self-service options will only take us into worse and even more expensive care.