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Me: This patient was admitted 10 times in the last year. She needs a good doctor to help her use the system better

Resident: Dr Perkins, she goes to the emergency room because she is an addict. And that is when she is taking her psych meds and not hearing the voices. She’ll only take the pain meds and won’t take any medicine for her diabetes or her blood pressure because they are (air quotes) poisoned (air quotes) 

Me: Don’t you want a challenge?

Resident: Her psychiatrist won’t tell us what medicine she is on or even whether or not he is actually seeing her. Claims it violates the (air quotes) doctor-patient  (air quotes) relationship. And don’t get me started about her drug problem. She has been kicked out of every treatment facility within 50 miles and there is ONLY ONE of them that take Medicaid, anyway. 

Me: Don’t you want a challenge?

Resident: Dr Perkins, don’t do this to me. Let me just refill the diabetes medicine that she won’t take…

Medicine in general has not historically functioned effectively outside of the here and now, meaning we try to fix broken people.  There is a parable that is often used to illustrate the problem with this approach, the parable of the babies in the river. In the story a village mobilizes to deal with a crisis (babies are found floating in a river) and the town folk eventually take on saving babies as their purpose. Finally, the story goes, someone suggests going upstream to determine where the babies as being put into the water. Delivering care to those suffering from complex illness in an academic health centers as I do is much like living in that village. We find ourselves pulling people out of the water meanwhile wishing someone could go upstream and fix the problem. Academic medicine has put together a list of things called the Milestones that our doctors should be willing and able to do. One of these suggests that family physicians should be willing to take that walk upstream and stop the babies from being put into the water in the first place.

The most complex patients do not simply need blood pressure and diabetes medications. Those who are “really sick” typically have multiple poorly controlled chronic illnesses, multiple physicians, and expensive care-seeking behaviors, and no primary care because they do not see a reason to add “one more doctor” into the mix. Also these are people who have problems with housing as either they tend to be impoverished from their illness or they suffer from illness as a consequence of their poverty. They lack access to healthy foods because they tend to live in food deserts associated with poor neighborhoods but also tend to require specialized diets that cost more. They also are more likely to have sought and receive disability and so must live on a fixed income. In addition these patients may have suffered from access to an over exuberant healthcare system and suffer the after effects of having had multiple surgeries and having been on multiple medications with serious side effects,

Atul Gawande wrote of a physician who focused on caring for these complex patients (information and link found here). Caring for these complex patients requires practice based resources such as timely access to clinical services and coordination of services, knowledge of community resources such as housing and healthy food, and a clinical quarterback. The payment structure, although changing, has not changed sufficiently to reward practices that “look upstream.” In addition, medical students and residents come from a model where “the here and now” is rewarded both financially and professionally so they are not looking to move “upstream.” For us to get healthier, our doctors need to be able to focus on the stream AND look upstream as well.

In our training site, we are working on create an nurturing and supportive environment that will allow us to care for these patients. Our hope is that we will allow our complex patients to receive better, more effective care.  Our hope is also that it will provide a lab for our students and residents to see that by partnering with the community, providing “non-medical” things such as housing and appropriate dietary information, and improving access to resources they can care for these patients in addition to providing care for the rest of the community. We will start building this “Chronic Disease Medical Home” annex to our patient centered medical home. I will use this space on occasion to  discuss our progress. Wish us luck!

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