Asking the Right Questions
 
            Alice H. Chen, MD, recently gave a talk about innovation in health care.[1] Her credentials are impeccable, having served in a variety of positions before her current one as San Francisco Health Network’s Chief Medical Officer and Deputy Director. She started her remarks by describing her approach to her first position as a medical director, where, like a typical doctor, she had diagnosed all the problems and developed solutions for them and then set about fixing them all at the same time. Some worked and “stuck,” some did not.
 
“The innovation that health care truly needs is not a shiny, new piece of technology, or a quick fix. It’s about new and different ways of thinking about what we’re really doing and to what end; and its about changing the questions we ask. The question we should be grappling with now: What is the purpose of our health care system? Is it to provide visits, diagnostic tests, and therapeutic interventions, or might it be to produce health?”
 
            Talk about a question designed to upset the apple cart! Most people I talk to about health care usually think in terms of how we can do what we do more, or better, or cheaper, or more profitably. (Not that these are mutually exclusive.) But almost everybody assumes what they we are currently doing is a key component of “the healthcare system.” Very few seem to consider that what might need to happen first is to stop doing what we are doing.

            The challenge is not new. Many years ago, I had the opportunity to interview the founding physicians of my medical group. The acknowledged thought leader, Leland Johnston, MD, had graduated from medical school in 1928 despite contracting tuberculosis with a year in hospital and taking time out to study with Dr. Goodpasture in the pathology department before graduation, and then chose to do a year in New York (Belleview Hospital) before going on with internal medicine training. I asked him what the greatest advances he had seen in his many years of practice. He told me about a patient who had contracted tularemia during WWII. He had heard of penicillin and had a friend in the Army Medical Department that he called and asked for a dose. The friend sent him a package of 5,000 units of penicillin on the bus. The patient was cured. When I asked him what, besides penicillin struck him, he replied “refrigeration.” During his time at Belleview he had seen many young children who died of bacillary dysentery from drinking spoiled milk. This “epidemic” went away once refrigeration became widespread. Even as an old man, he was still thinking outside the box.

            So, what sacred cows should we be questioning now? I Your list might differ from mine because the challenges facing your health care system might be different. But here are some that are on my list. For clinicians: “the EMR will improve patient care and patient safety.” (A corollary: AI is the wave of the future.) Medicine is based on data, so it is difficult to dispute that better data are important for advances to occur. But, I remember seeing a patient from a Middle Eastern country who had previously seen a Harley Street consultant in London about her problem. She had a copy of his “encounter note,” which she shared with me. The consultant had hand-written a conversational letter to the referring physician in which he outlined her story, his observations, and his conclusions. At the time, we in the US were focused on “SOAP” notes and a telegraphic style of communication, and I realized there were some positive aspects of the old system that we had lost.

             Now, in our worship at the feet of “objective” data, we have elevated it in our notes to the point where narrative and subjective context have disappeared. Perhaps they have disappeared from our thinking, too. But is this what we are about? Are we production workers who make sure all the recommended actions get done? Or are we knowledge workers who struggle to place the recommended actions into the patient’s context?

            I have been doing telecommunication consults with providers working in charity clinics and recently talked to a PA working a street clinic who had a patient with progressive diabetic nephropathy. She wanted to be sure she was doing what she could, which she was. But I pointed out to the PA she was probably the only healthcare worker the patient trusted, so she needed to discuss dialysis with her and explore what, if anything, the patient was willing to do. She replied that she had and did not want dialysis. Living on the street is not compatible with getting a good clinical result from dialysis, but the next time she gets sick and ends up in the ED, odds are she will get dialysis anyway. Is this good care?

             For administrators: “more, and new, is better.” Perhaps this was true once, but is it true now? For inpatient admissions of Medicare patients, payments are fixed in a narrow range; few hospitals make money on that book of business. Yet, I have heard presentations designed to show that the necessity of increasing that business even if money is lost. A similar argument is made for new technology. If we don’t have the new whiz-bang gizmo, the fellows down the street will get it and “steal” all our patients. Some new things are valuable because they make things better. Laparoscopic surgical procedures come to mind as a real improvement occurring in my era. Imaging methods have also shown dramatic improvements. But some new things are changes that have marginal to no benefit for patients. However, one thing has remained constant—patients don’t want to be in the hospital. Maybe we all need to learn to see hospitalization as a “failure” of the care system, not as a revenue opportunity.

            Lastly, we all need to come to grips with our curative mindset. Our collective memory is the patient with tularemia cured by small doses of penicillin. Yet most of our care is trying to extend the functional life of patients with various chronic conditions we cannot cure. We also put a lot of emphasis on “preventive” measures, but few really pan out on closer study. It doesn’t mean we should not try to ameliorate progressive diseases, but we need to quit thinking about it as the “cure” for our current dilemma. Lewis Thomas labeled maintenance hemodialysis as a “half-way technology.” That was true then, and is true now, but it is also true for most of what we do. Perhaps the answer to our affordability problem is to recognize that “more is better” is not true for clinical practice anymore than it is for solving financial problems in healthcare organizations.
 
4 February 2020
 
 


[1] Chen, Alice H. Health Care Innovation to What End? Asking the Right Questions. NEJM Catalyst, 14 January 2020. Accessed at https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0016?query=CON&c. 15 January 2020.

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