My wife and I were invited to dinner at the home of one of my daughter’s friends. My daughter is a graduate of the International Baccalaureate program of Murphy High and her friends tend to be interesting (if not a little nerdy). This particular friend is majoring in pre-med and has parents who immigrated from Vietnam following the fall of Saigon. As is usual when one has a physician dinner guest (and perhaps when one doesn’t) the conversation turned to mutual acquaintances and the interactions they have had with the health care system. One particular discussion, although I have changed the circumstances a bit, illustrates one of the concerns that I have with health care reform.
The story was about a mutual acquaintance who happened to be Vietnamese and had an untimely death. He was not cared for by me or any of my close colleagues so the circumstances always remained a little unclear to me. The word in the community was that he had been feeling poorly for a bit before his death. My host reported that he went to seek medical care (“all he saw was his family doctor”), was placed on some medications, and later died. As the conversation progressed, other speculation was that he may not have taken the medication (Vietnamese don’t like to take medication if they don’t feel badly) and he otherwise may not have been a full participant in his care (western medicine is too strong). My hosts, who speculated that cardiac disease was the cause of his death, implied that if he had only seen a cardiologist things might have ended differently. I have to admit that part of me had a pang of regret as well…
The problem is communication. The pre-patient attempting to interpret his or her own symptoms (are they bad enough to seek care, who should I seek care from, if I don’t feel better) is often discouraged from easily communicating with a live human being who could assist with this interpretation. As it turns out, up to 58% of all Americans use the Internet to determine how and when to access other health care resources. This resource, while offering the world’s information, does not facilitate personalized interpretation. This particular person’s health symptoms were made more difficult to interpret because of the circumstances (when you survive near starvation in Vietnam living on cassava you don’t complain about a little chest pain) and residual health beliefs brought in from a previous culture (well documented by Anne Fadiman in “The Spirit Catches You and You Fall Down”)
How could this have ended differently? Maybe not at all, as people die of heart attacks all the time. If it were to have ended differently, it would have been as the result of an improved interface between the person who might be sick and the health care system. The Advanced Primary Care model offers one such model. The patient would be in a relationship with a TRUSTED Family Doctor (or his or her staff) who could help with personalized symptom interpretation prior to becoming ill. Second, this TRUSTED Family Doctor will be able (by virtue of a changed payment structure) to take sufficient time to determine if there are special needs (communication, residual illness beliefs, etc) that would need to be dealt with at the time of a visit or while engaged in other types of communication. Thirdly, this TRUSTED Family Doctor will be willing to work with the patient to overcome these barriers and facilitate optimum care NO MATTER HOW LONG IT TAKES.
Obviously, I feel strongly that we can and should be practicing in this manner. Why do we not? First, I believe that we as a country have a love affair with technology and feel more comfortable relying on specialist-controlled technology for symptom interpretation in the same manner that we like the mechanic to “hook the car up to the computer.” Trying to convince the average person that a “Level 1 Diagnostic Scan” is worse than worthless is going to take a lot more than me saying so. Second, spending time with the patient is not why doctors currently get paid. Insurance companies have been quick to reward doctors for using technology (under the mistaken belief that it would make the system more efficient) and have been slow to develop ways to reward extended interviewing and risk analysis based on multiple methods of information gathering. Third, I suspect we admit students into medical school who prefer interacting with technology to people interaction. Insurance reform has happened. Now lets discuss real health care reform