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ÒDaddy, can I stop being worried now?ÓText from my daughter “Should I worry about Ebola”

Text back from me “Are you considering moving to west Africa?”

My first class in medical school was in our freshman auditorium. The Dean (or someone who looked old, must have been about 50) came up to the podium and said: “This is a great time to be a doctor. When I was sitting in your seat, the person at the podium had us look to our left and to our right and then said “Of the three of you, one will not be here by the end of the 4 years because of tuberculosis.” You, fortunately, do not have to worry about that.”

Tuberculosis, I thought. What the heck is that and of course I’m going to worry about it (I remain uninfected to date).

When I was a third year medical student, AIDS hit New Orleans. I remember being on an infectious disease rotation and going into the emergency room where an emaciated man with blue tumors (Kaposi’s sarcoma, I now know) all over his body was in “isolation.” The isolation, in this case, was no one placed in the bed next to him (it was an open bay ward) and yellow CAUTION tape placed across the entrance to the bay where he had been placed. My attending, who remains a role model to me, tore the tape down and said “Whatever you THINK you are doing with this tape it is accomplishing nothing except dehumanizing this person who is ill.” The patient died. None of us on the health care team became ill.

Ebola virus is the latest illness to capture the public’s attention. Confined to west Africa unless those ill are transported, it has claimed the lives of 1427 people, about 10% of whom are health workers. Apparently my daughter’s text was prompted by the news reports associated with the transport of the American physician to Atlanta. Spurred on by movies like “Outbreak” and breathless news reports from Dakar by Ofeibea Quist-Arcton (pronunciation found here), folks here are concerned WAY out of proportion to what they should be (unless their neighbors are west African health care workers who just got back and appear mighty sick). Americans should worry about a lot of things: their diet, their lack of physical activity, their use of tobacco and guns. “Ebola” should be appear on the list below “death from bee sting” (100 Americans annually)

Turns out that Ebola is big news because people tend to make many decisions based on feeling and belief rather than based on a calculated risk assessment.  Psychologists have coined the term “Dread Factor” for the combination of

  • perceived lack of control,
  • catastrophic potential,
  • fatal consequences, and
  • the inequitable distribution of risks and benefits.

Ebola (0 deaths in America) hits the sweet spot. We humans worry more about what we can’t control, especially if the long term consequences are unknown, the potential risk is believed to be high, and there is nothing we can do to mitigate it. In “Perception of Risk Posed by Extreme Events” Peter Slovic points out that, probably as a result of eons of programming, we worry excessively about things such as a satellite falling out of the sky and hitting us (0 human deaths so far) and worry very little about backyard swimming pools (10 Americans die A DAY). Makes setting public health policy difficult. If you don’t believe me, look at the backlash regarding Michelle Obama’s healthy children initiative to reduce obesity (1375 American deaths A DAY).

Fine, you say, I know that smoking is unhealthy. What I don’t want to do is die from Ebola.What can I do? Turns out, a lot.

As a health care consumer, make your concerns known. If not dying from Ebola is the most important thing to you, let your doctor know. He or she might suggest something simple, like avoiding travel to the remote villages of west Africa. Meanwhile, take some time to understand why worrying about other elements of your physical well-being might be more useful in the long run.

As a health care professional, don’t just dismiss your patients’ concerns. Listen to them and provide information about why these fears might be unfounded. By the same token, don’t take advantage of your patients’ irrational fears. Providing excessive testing is expensive and often is less helpful than a frank discussion on risks.

We humans react instinctively (on feelings) and intellectually (based on rules and empirical evidence). We often make decisions based on feelings (I am unsafe and need a gun) that run counter to evidence (a person with a gun is 22 times more likely to kill a family member than a bad guy).

As physicians, much of what we do (and don’t do) affects health in a limited fashion. Perhaps we need to get better at helping people to overcome their own barriers to achieving health instead of offering tests for scary things we know aren’t going to happen because “the patients want them.”

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I like reading what Atul Gwande has to say, despite the fact that he is a surgeon. I was sent a link to the commencement address that he gave this season to the graduates at Harvard Medical School. I have sat through a number of these and typically am underwhelmed but this one is worth a read in its entirity. There are two passages in particular that I want to call attention to:

“[The values needed for medical practice] include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy These values are the opposite of autonomy, independency, self-sufficiency.”

This is what medical school curriculum has to focus on and I’m afraid we are not getting it. We seem to still be in the “science of discovery” mode and not the “science of synthesis.” This quote needs to go to everyone on the curriculum committee of every medical school in the country.

And for the admissions committee members:

“The revolution that remade how other fields handle complexity is coming to health care… I see this in the burst of students obtaining extra degrees in fields like public health, business administration, public policy, information technology, education, economics, engineering. Two years ago, the Institute for Healthcare Improvement started its Open School, offering free online courses in systems skills such as outcome measurement, quality improvement, implementation, and leadership. They hoped a few hundred medical students would enroll. Forty-five thousand did.”

Atul Gawande has put faces on the Accountable Care Organization potential. He is the author who put a face on Medicare spending in his documentation of the differences between doctors in McAllen Texas and Grand Junction Colorado which I wrote about here. In this months New Yorker he writes of primary care intervention in Camden New Jersey making a difference in an article entitled “The Hot Spotters.”

He first interviews a Family Physician named Jeffery Brenner who has devoted his professional career to trying to determine why folks who utilize a lot of health care do so and figuring out what can lessen costs. He figured out quickly that

“People are people, and they get into situations they don’t necessarily plan on. My philosophy about primary care is that the only person who has changed anyone’s life is their mother. The reason is that she cares about them, and she says the same simple thing over and over and over.”

In other words, for a lot of people, a caring health care professional (coupled with knowledge of resources brought in by other professionals) was often (50% of the time) sufficient to dramatically reduce emergency room visits and hospitalizations

“High-utilizer work is about building relationships with people who are in crisis,” Brenner said. “The ones you build a relationship with, you can change behavior. Half we can build a relationship with. Half we can’t.”
The outcomes are impressive. When the first thirty-six super-utilizers from another group using the same techniques were studied in depth, they averaged sixty-two hospital and E.R. visits per month before joining the program and thirty-seven visits after—a forty-per-cent reduction. There was a fifty-six-per-cent reduction in hospital costs, hospital bills averaged $1.2 million per month before and just over half a million after.
As Dr Gawande emphasizes
The critical flaw in our health-care system that people like Gunn and Brenner are finding is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the E.R. visit. (Americans make more than a billion such visits each year, according to the Centers for Disease Control.) For a thirty-year-old with a fever, a twenty-minute visit to the doctor’s office may be just the thing. For a pedestrian hit by a minivan, there’s nowhere better than an emergency room. But these institutions are vastly inadequate for people with complex problems: the forty-year-old with drug and alcohol addiction; the eighty-four-year-old with advanced Alzheimer’s disease and a pneumonia; the sixty-year-old with heart failure, obesity, gout, a bad memory for his eleven medications, and half a dozen specialists recommending different tests and procedures. It’s like arriving at a major construction project with nothing but a screwdriver and a crane.
Obamacare, anyone?

There is an ongoing argument between the people who say we have too few doctors and the people who say we just don’t have the right kind of doctors (it’s quality not quality). More evidence that more is not better, better is better, and better is Family Medicine was put forth once again in the New England Journal of Medicine recently. Thomas Bodenheimer and David West went back to the town that Atul Gawande wrote about in his classic New Yorker article about run away health care costs. Not McAllen Texas (the town with the highest cost) but Grand Junction Colorado (the town with the lowest cost) to see why this town succeeded where others failed. They went there because

The usual explanation is that this town of 50,000 benefits from a cooperative spirit among health plans, hospitals, and physicians, who work together to serve the population. But even if this explanation were accurate, cooperation could not be transferred to other geographic areas — nor could the small-town nature of the Grand Junction community with its relatively homogeneous racial makeup. So what aspects of the Grand Junction success story might be replicable in other communities?

What they found was

that seven interrelated features of the health care system that may explain the relatively low health care costs could be adopted elsewhere. These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care.

It wasn’t just any type of “primary care” physician, it was Family Physicians. These physicians created a culture of accountable care before it was popular. The fixes were not high-tech (in fact, several such as pay equity are exceedingly low tech) but they have created a culture of exceptional care.

A lesson for America? Perhaps. In the understated words of the authors

These features could be replicated in other markets — though generally not without political battles.

Accountable Care Organizations, anyone?

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