Over the holiday, my mom’s good friend lost her father. When I asked how they were doing, my mom said that although it was devastating, they all know he is in a better place and they are “lucky” he left peacefully and didn’t have to suffer. A week before, I used the same word after a family’s test result came back negative. Wow, we are so “lucky” I kept saying….
Returning to Colorado, I bought a new book by Joanne Lynn that I’ve wanted to read. The book, Sick to death and not going to take it anymore! Reforming health care for the last years of life begins Chapter two with the following quote: “Facts are like geography – they shape the possibilities. Interpretations are like politics – they create the human structures and meanings.” After reading this, I thought about our (and my) use of the word “lucky” in creating human structures, interpretations and meanings of our experiences and how it was similar and different to a system built on participation…
Lynn’s overarching question from the outset is “why do we tolerate a health-care system that leaves people in pain, confused, bankrupted, demeaned, and frightened?” What should we do aside from relying on luck? For Lynn, “we need most a shared vision of good care, innovative approaches for achieving this vision, and the will to make the changes happen.” That said, I am going to discuss four ideas or practices that are gaining momentum. Ideas that allow care to be different, collaborative, and participatory, instead of lucky…
Atul Gawande has been busy publishing his most recent book, The Checklist Manifesto that is an extension of his earlier article in the New Yorker about checklists for surgeons, similar to the checklists pilots use. Gawande addresses the need for such checklists by putting medical errors into perspective by stating, “Annually, medical errors disable at least 7 million people and kill 1 million worldwide – the equivalent of six sold-out 747s crashing every day, killing everyone on board.” Sure, treating a patient suffering from multiple conditions is far more complicated than flying a plane, but this statistic certainly puts things in perspective. According to Malcolm Gladwell, “Gawande thinks that the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help.” The solution? No, not more training or technology but checklists. “Did we get the blood ready?” “Does everybody in the room know each other’s name, so we’re working as a team?” Why a checklist? Well for Gawande, steps are being missed and complications are occurring that are avoidable. Even more, these lists are facilitating people to work less as individuals and more as part of a team. In so doing, the boundaries around expert, expertise and professional begin to be defined and celebrated by the willingness to work together, rather than alone. And this matters for increasingly complex practices, drugs, diagnoses and patients.
Although checklists might seem silly, according to Gawande, they do matter for a complex system that cares for highly complex patients. Valderas et al (2009) in the Annals of Family Medicine discuss the norms and expectations of caring for individuals with multiple coexisting diseases. In the United States, the authors underscore “about 80% of Medicare spending is devoted to patients with 4 or more chronic conditions, with costs increasing exponentially as the number of chronic conditions increases” (p. 357). The words “comorbidity” and “multimorbidity” are often used synonymously when discussing these issues. But the important thing to consider is knowledge about the role of psychological issues in medical patients with multiple chronic diseases. Clearly, this is challenging for providers, families and patients because complexity in these patients has not been clearly defined, thereby designing interventions to improve their care is difficult at best.
Increased interventions and improving care is making great strides, especially in light of Kaiser Permanente’s idea of “Thrive” and “Total Health.” Both ideas shed light on the innocuous details of health care environments – plants, waterfalls, windows, patient rooms, transparent hospital gowns, a blaring news station in the waiting room and so on. “Total health” becomes a method for designing and building new facilities or renovating existing ones. These efforts are not necessarily about decorating or adding more flair, they are about outcomes. For example, access to natural light, noise level in the halls, privacy of rooms, or views or nature. Together, the new designs enable workers to do their work more effectively (and make it more pleasurable) and allow design to be about building healing rather than curing environments. Design takes a new spirit by building in a way that not only improves the lives of patients and families but also for providers, who do this work.
Improving the working conditions for providers brings awareness to the many hands called upon to deliver care. Hands we often take for granted like helicopter EMS. According to Rogue Medic and an article written by Michael Abernethy, MD, Bryan Bledsoe, DO & Dale Carrison, DO, HEMS transport is the only medical procedure that holds a much higher morbidity and mortality for the providers than it does for the patient. Why don’t we hear about the risks and mortalities? What don’t we help develop safer procedures? Is a safe transport considered “lucky”?
Finally, returning to Lynn’s question at the beginning, many of us do not tolerate a health-care system that leaves people in pain, confused, bankrupted, demeaned, and frightened. The examples above show that changes – and good ones indeed – are taking place. Sure, there is plenty of work to do but the conversations have started and we can either dwell in the misery many of us feel about our health care system and health care reform, or we can find some light and hope in what is taking place. I remain a little more optimistic because there is a difference between a system that relies on luck and individuals working alone and a system that fosters participation and celebrates what happens when people work together to deliver care…
The whole is always greater than the sum of its parts.