The power of the painting is the gaze of the doctor on his patient. Now is the place, the time, the person – he has no other thoughts or concerns except to assist her back to health if he possibly can. We do not know the medical problem, but we can infer it is serious. And we do not know the outcome, although there may be a clue because through the window comes a faint ray of light.

I did not fully appreciate the implications of this work of art when I first received it, but I came to understand that this physician was a healer. He had listened; he was nonjudgmental; he had earned trust. He has done his best but understood that he alone would not be her cause of cure should a cure ensue. He understands that he is but a humble person entrusted with the most important of all missions – to assist others in finding health. He has done his best and, in doing so, exemplifies the characteristics of a healer.

My maternal grandfather, Leonard McClintock, MD., was a general practitioner in New York state. He graduated from Albany Medical School in 1898. He set up his practice in what was then a small town on the Hudson River, Beacon, N.Y. He built a room on the side of their home to serve as his office and used the large wraparound front porch as the waiting room. There were no appointments; you came and sat on the porch until it was your turn. Office hours lasted until the last patient had been seen. 

Initially, there was no hospital, and he cared for all patients in the office or at home, although later in his career, he helped to establish a hospital directly across the street. In his day, a physician had relatively few tools to treat someone, so the skill was to make a diagnosis and inform the patient and the family what the situation was and what the course of that illness would probably be. Yes, he could do some things, including treating pain with morphine, removing an inflamed appendix, sewing up lacerations, and delivering babies much more safely than could have been done without the assistance of a trained clinician. 

But during the course of his practice, which ended with his death in 1936, medicine began to change toward a much more scientific basis. To a large degree, this was propelled by the influence of Johns Hopkins University School of Medicine and Hospital in Baltimore, MD. Founded in the late 1800s, it instituted the concept that medicine was and should be a science. Therefore, Johns Hopkins would teach a science-based medical practice during four years of medical school. In addition, Hopkins established what we know today as the standard residency training program following medical school. 

This was a dramatic change in medical education and training and, as a result, dramatically changed the way physicians thought about medicine and patient care. During my grandfather’s practice, he began to see the beginnings of those changes. For example, insulin was discovered in the 1920s, and the first antibiotics in the 1930s. After his death and the completion of World War II, the National Institutes of Health began to develop, grow and place large sums of money across the country in various medical schools and within its own walls to conduct basic biomedical research. 

The result is that today our ability to repair, restore to function or replace an organ, tissue, or cell has moved ahead at a dramatic pace and will do so even more quickly in the coming years. Concurrently, the pharmaceutical industry also became scientific, resulting in a continual outpouring of new drugs that can relieve suffering, reverse harm and cure many diseases while extending our life span. In addition, with the advent of the science of genomics, it is increasingly possible to predict the onset of illness before it occurs and thereby create a preventive approach for the individual patient.

Soon we will have immediate access any time, any place to our medical records, which will be fully digitized, and the safety and quality of medical care will dramatically improve. All of this is because of the science base of medicine, which was introduced over 100 years ago.

Something else has happened, but it has not been appreciated. In the past, illnesses tended to be “acute,” meaning that they occurred, were treated, and got better, or the individual died. For example, if your child developed “strep throat,” the pediatrician gave an antibiotic, and it got better. If it was an inflamed gall bladder, then you were referred to a surgeon who operated, threw away the gallbladder, and you were cured. But today, most illness is chronic and complex as well. For example, if a person survives a heart attack, he may still have some damaged heart muscle and so develops heart failure. This will be with him for life and will need multiple treatments, many medications, probably multiple hospitalizations with an ICU stay or more, and might even get to the point of a heart transplant.

Now that is chronic, and that is complex! So it is also with diabetes, rheumatoid arthritis, many cancers, chronic lung disease, kidney failure, and many other diseases are frequently seen today.

This is a major shift and enormously impacts how we should [but mostly do not] organize the treatment of the patient and their disease, how we should [but mostly do not] organize the payment system for that care, how we should [but mostly do not] use technologies wisely for maintenance, and how we should [but mainly do not] assure quality and safety in patient care.

This is a profound change, but most of the “healthcare reform” approaches do not address the implications of this change to chronic, complex lifelong illnesses. Although aware of the change toward more and more chronic diseases, physicians also tend to want to preserve their current practice patterns developed over the years to handle acute illnesses, even though the current chronic, complex diseases require a different approach.

But in that same time frame of scientific advancement and the rising frequency of chronic illnesses, we also began to lose something in medicine. That loss is the genuine “connection” between the physician and the patient. Most of us feel we do not have enough time with our physician; the physician seems busy and distracted, often by the computer, and not able or willing to listen to our story in full. 

From the physician’s perspective, they feel that there is not enough time to spend with an individual patient; not enough time to learn about the family and the environment in which that patient lives, and therefore in which the patient’s disease has occurred; that there is not enough time to focus on preventive instructions or to even talk thoroughly about the plan for the care of a specific illness or problem. But all too much time is spent following mandates, filling out forms, often repeatedly, and then being paid by the insurer well under what the time and effort were worth. Physician burnout has reached epidemic proportions.

Today we need to preserve our newfound skills and techniques, drugs, and devices but also remember that patients are human and need empathy, caring, and attention, not just technology. Equally, providers need the ability (time) to give the care they were trained to provide, the care most wanted to give when they first decided on medicine as a career.

Unfortunately, rather than a true healthcare system, we currently have a dysfunctional American medical care delivery system. We need a healthcare system, but the cards are stacked against it. That said, it can be changed. Probably not by Congress, nor by the insurance companies but only by the unique interaction of doctors and patients demanding what is and could be the very best. Concurrently, one of the best ways to change the system is for companies to realize that they can secure better medical care for their employees while augmenting health and wellness, which will dramatically reduce the company’s and their employees’ costs. That is a win-win all around.

In later articles, I will outline further what patient and their doctors can do to improve care and what employers can do to create true healthcare for their employees.

The post Healthcare and Medical Care Are Not the Same – The Difference is Very Important appeared first on Medika Life.

My friend Susan in the first article of this series was a good example. Presenting to her PCP with a somewhat unusual symptom, she was sent from specialist to specialist without ever learning what was causing her symptom, much less resolve it. It was a true waist of time, money and her emotions when the answer was there if only a doctor spent some time to listen to her.

To further exacerbate the problem, the doctor and patient no longer have a “contract;”. The patient and doctor are bystanders to the decision-makers. Frustration by doctors and patients is high, and physician burnout has become rampant.

 Add to this is a significant change in the common serious diseases – complex, chronic illnesses, mostly preventable, for which American medical care has not established suitable methods of prevention or adequate methods of care. In addition, what should be the role of the primary care physician has been compromised by the insurance industry (both commercial and government-sponsored) that puts the incentives in the wrong places. The result is a sicker population, episodic care, and expenses that are far greater than necessary.

Our current delivery system was designed early in the past century with the expectation that the patient would pay the doctor a reasonable fee for the effort, skill, and time involved.

Insurance developed during the past 70 years initially to pay for unexpected, highly expensive care, such as surgery or hospitalization. But over time, insurance transitioned into what is essentially prepaid medical care and along the way eliminated the financial “contract” between you and your primary care physician (PCP or Nurse Practitioner.) The contract today for both you  and the doctor is with the insurer The patient and doctor are bystanders to the decision-makers. Frustration by doctors and patients is high, and physician burnout has become rampant.

Worse yet, insurance pays primary care providers a pittance, driving them to “make it up in volume” by seeing too many patients per day, often 24 or more. Of course, this means short visits, perhaps three per hour, which translates into about 10-12 minutes of actual face time with you.

The delivery system was developed to deal with acute medical problems, where it is reasonably effective. For example, consider the pneumonia that a single internist can treat with antibiotics, an appendicitis that can be cured by the surgeon, or the fractured arm that the orthopedist can cast. But our medical care system works poorly for most chronic medical illnesses and costs far too much. Chronic illnesses include diseases like diabetes with complications, cancer, heart failure, chronic lung and kidney disease, and Alzheimer’s.

These chronic illnesses are increasing in frequency at a rapid rate and consume the bulk of health care expenditures. They are largely (although not entirely) preventable.

A century ago, the most common causes of adult death were infections – pneumonia, typhoid, and tuberculosis. Today these are uncommon and treatable. Now the most frequent causes of death are chronic illnesses – heart, cancer, and stroke, with Alzheimer’s and diabetes just behind. Other than some cancer, most others are not curable.

Most chronic diseases are related to lifestyles and are preventable. A myriad of social, environmental, financial, and personal reasons has led to non-nutritious diets, lack of exercise, chronic stress, inadequate sleep, smoking, and excess alcohol. Obesity is now a true epidemic, with one-third of Americans overweight and one-third obese. The combined result is high blood pressure, high cholesterol, and elevated blood glucose, which, combined with the long-term effects of the above behaviors, leads to diabetes, heart disease, stroke, chronic lung problems, kidney disease, and cancer.

No one pays for prevention, for maintaining health and wellness. Insurance is for disease care. Government does little (except with tobacco) to assist. As a result, as a country, we do not attend to actual healthcare and maintaining wellness, which in turn means greater pressure on the medical care delivery system. We don’t have a health care system, it is a medical care system that focuses on disease, its diagnosis, and treatment. Wellness and prevention are largely ignored. That is unfortunate because most of today’s chronic diseases could be prevented. Attention to prevention is the logical method to maintain and improve health and is much less expensive than treating a disease once it occurs.

When any of these chronic diseases develop, except for some cancers, it usually persists for life. These are complex diseases to manage and are often very expensive to treat – an expense that continues for the rest of the person’s life. Preventing them is equally complex but a lot less expensive.

Although not adequately appreciated, primary care physicians can handle most of today’s chronic illness care. They have the knowledge, experience, and skill level to do so. But this does not happen with short visits. All too frequently, the patient is referred to one or multiple  specialists when the PCP could have dealt with the problem had they had enough time. That extra time would not have cost much, but the referral, of course, means an increase in the costs of care, often substantial.

Some patients with chronic illnesses will need a team of caregivers, but the various specialists and the PCP are not a true team working in a unified manner. For example, consider a patient with lung cancer who may need a surgeon, radiation oncologist, medical oncologist, pulmonologist, pain specialist, palliative care team, nurse practitioner, and many others. Primary care physicians generally do not have the time needed to coordinate the care by the specialists. This is very unfortunate because coordination is absolutely essential to ensure good quality at a reasonable cost. You might think that one of the specialists might take on that role but that rarely occurs. More often the patient starts with a surgeon who refers him on to a radiation oncologist who then refers to a medical oncologist who then may or may not call-in others as needed. 

Any team needs a quarterback, and in general, that person is or should be the primary care physician. The PCP needs to be the orchestrator of the various specialists when needed in these complex patients. This need for a team and a team quarterback for the patient with a chronic illness is much different than the needs of the patient with an acute disease in which one physician can usually suffice. A team quarterback dramatically reduces the total costs of care if only because it means continuity and organization of care, keeping the patient’s welfare upper most in mind.

This shift to a population that has an increasing frequency of chronic illnesses mandates a shift in how medical care is delivered. Unfortunately, our delivery system has not kept up with the need. This is no way to run a railroad.

Join me with the following articles as I address more of the Whys and Hows and What to Do.

The post Complex, Chronic Diseases Are Rampant Today appeared first on Medika Life.

Not too long ago, our family joined the rare disease community. For years, our child exhibited a multitude of disconnected symptoms that all seemed to have different explanations, if they had explanations at all. The growing list included dizziness, rapid heart rate, stomach aches, rib pain, joint pain, unexpected dislocations, migraines and others.

Spider-Web-like Health Ecosystem

The symptoms accumulated, along with a cascade of specialist appointments, diagnostic tests and treatments. So did the hours of speaking – and negotiating – with our health insurance carrier. Along the way, we encountered all sorts of personalities in our spider-web-like health ecosystem, most compassionate and wanting to help our child, others bewildered or frustrated, and still others deaf to our worries and requests. The boldest and best among the health professionals we worked with were those willing to confess their uncertainty. In medicine, the response “I don’t know” is now an act of courage.

Fifty years ago, when modern medicine came of age, there were far fewer treatments for common, non-communicable diseases such as high blood pressure, cardiovascular diseases or mental illness. While medicine has become more advanced and specialized, it has also become increasingly fragmented. The important family physician – who should have sufficient time and compensation to coordinate care – is often out-of-the-loop as patients rush to a myriad of medical specialists – each hyper-focused on their piece of the biological puzzle.

Fee-for-service care disadvantages primary care medicine and a patient’s coordinated care.  This financial model may work for simple – in and out – cases, but when it comes to chronic illnesses, it does not. Add to that the complexity of electronic medical record systems with limited interoperability. Now, specialists face “telephone-game” obstacles to accessing colleagues’ clinical notes and diagnostic data for a shared patient.

Now, shift from common non-communicable diseases to needle-in-the-haystack conditions.  It’s baffling for patients, parents and providers.  Over time, doctors may even become frustrated with these patients. People with multiple, disparate symptoms with no “one pill to heal them all” are sometimes labeled problem patients owned by no one. In these circumstances, young female patients often experience gender bias and provider judgments that the puzzling symptoms must be “in their heads.”

Communication is Part of the Care

When you hear hoofbeats behind you, think horses, not zebras. As 14^th-Century theologian and philosopher William of Occam would suggest, the more common explanation is the correct diagnosis. But medical students – and the doctors they become – need to be careful not to develop a foolish consistency.  This is not the Middle Ages of Medicine.  It is the 21^st Century of miracle medicine where patients must have a voice.

While it is easier to treat confusing and contradictory symptoms than to ask why a patient is experiencing them, savvy doctors rely more on their patients’ collaboration to help them solve medical mysteries. Information, communication, and advocacy can build a bridge linking doctors and patients.

Traumatized by the Medical System

But, most often in healthcare, the gatekeepers – providers and payers – feel they know best. This overconfidence can quickly unravel in the face of the challenges of rare whack-a-mole diseases. Physicians trying to help feel helpless and grasp at straws when their initial diagnoses and treatments do not solve their patient’s problems. Over time, many patients are traumatized by a medical system that seeks to help, but is seen as fallible.  As different solutions are sought, the system pays more and more for that same patient over time. The patient’s underlying illness remains unaddressed. No one wins.

This two-decade journey to arrive at my child’s diagnosis (Ehlers Danlos Syndrome) has taught me several lessons.

• TEAM:  Any successes result from the passion of individuals —parents, physicians, payers or policymakers — who are determined to work together to find solutions and willing to listen.

• TECH:  Good health information begins to force our fragmented health system to converge around the patient. When data is accessible, artificial intelligence finds needle-in-a-haystack solutions, uniting the myriad of like cases so that health professionals can learn, engage, and arrive at answers sooner.  Physicians who also engage patients promptly through the EHR system are more than answering the questions of anxious patients; they demonstrate partnership in the care.

• TRUST: I have seen how critical advocacy is. As a health communicator, I have been fortunate to serve on the boards of organizations such as the American Academy of Pain Medicine Foundation, American Heart Association, Leukemia & Lymphoma Society, The Marfan Foundation and Let’s Win for Pancreatic Cancer, which unite healers and patients, and participate in the Centers for Medicare and Medicaid Part D Working Group: all great forums for accurate information that improve public health through informed decisions.

These lessons all point to passionate, informed collaboration as the key to restoring clarity and sanity to the fragmented health system and driving quality care for patients, whether they have common ailments or rare conditions. I integrate these lessons into my work to benefit clients and, most importantly, change the lives of the patients they serve.

Our family’s lives were changed by one cardiologist who dared to utter a simple sentence: “You need a team.” Her idea to put one together should not have been so revelatory, nor so atypical, but it was. She understood collaboration fundamentally and saw patients and their caregivers as her partners in healing.

Collaboration – Overused Word; Underused Strategy

For those whose work touches patient care and public health, I encourage you to collaborate, talk, and merge your experiences with others. Remember, this work directly touches people’s lives. This work makes a difference. Give thought to how you can bond with others to change the course of care. Collaboration is an often-overused word but is too often underplayed as a behavior.

I call on my readers and colleagues to look to the innovators of ideas, products and relationships and recognize that through collaboration with each other, we have an opportunity to recast the health ecosystem. Recognize that our work is a life-saving effort about being part of people’s transformational moments. And be courageous enough to know when you don’t know.  From there, we can begin the journey toward healing, together.

The post Looking for Zebras: Medical Mysteries and Transformational Patient Moments appeared first on Medika Life.