Tag Archives: patient centered

Atul Gawande on healthcare: 15 Cooks in the Kitchen and Nary a System in Sight

Maine’s Quality Counts! just had their annual conference. The statewide aggregator for health improvement, blessed with great leadership, partnership and a following, did a fantastic job getting 1,100 people there and bringing in phenom speakers.

A conference highlight was Atul Gawande @AtulGWande. Dr. Gwande, renowned in healthcare and quality circles, a surgeon at Brigham and Women’s Hospital, writer for The New Yorker magazine and best-selling author of 3 books (Better; The Checklist Manifesto; and Being Mortal: Medicine and What Matters in the End).

You can watch his full Quality Counts! presentation on YouTube:

Gawande talked about how healthcare has become so sophisticated, with 4000+ procedures and 6000 medications (is that all?), has tremendous science, with a capability to provide care to almost every person in every town. Yet we continue to drive up costs and resource use. He said that in 1970, for patients with pneumonia and heart attacks, it took 2.3 FTE of care. Now for the same patients, we need 15 FTE. 15 people who all know the plan. We’ve become specialists – but silo’d, and separated from communities. Most importantly, we don’t really have a system. We have to put health and healthcare together.

We have extraordinary technology. We are the best trained, over-educated, but with no sense of how it comes together.

Gawande spoke about how we’ve become obsessed with having the best components in healthcare. But patients may not necessarily care about living longer. How do we find out what people really want? Their goals? Priorities? Then he said an amazing thing: ASK THEM.

To do this, we as health professionals need to stop talking. We have to stop being “explainaholics“.

Some of his comments had inherent tensions. Data, measurement, quality, checklists. Then, he mentioned rigid rules for older folks in nursing homes. Rules for eating. Rules for movement. Rules for behavior. He noted what people want is to optimize their autonomy, as long as they can. Being able to eat a cookie (or have a refrigerator to open when they want) can be a simple solution with key rewards. Tangible and intangible, if you ask me.

Can we measure and focus on data, at the same time also really care? I think we have some ways to go. To measure what people value, rather than to value what we measure

Gawande had some great things to say about Maine, where we have some great improvement efforts and tremendous collaboration.

I look forward to curling up and reading Being Mortal, which I picked up at the conference. I don’t mind, though, that he slipped out of the Civic Center before he signed my copy. It was a treat to have him in Maine. To Lisa Letourneau, Director of Quality Counts: strong work, girl! 😉

Read – Jackie Farwell’s post, What Atul Gawande, medicine’s rock star, thinks about Maine health care

What part of Patient Centered Care do medical guilds not understand?

Update: Two days after the NY Times story, the American Board of OB/Gyn modified their rules allowing members to treat men for STDs and screen for anal cancer. That’s Patient Centered (and member centered)!

I try to stay positive. My dear colleague Ted Eytan says he’s “3/4 full” – I love that. Staying positive in health care can be a hard these days. Here’s an oxymoron for today: Patient-Centered Organized Medicine.

Patient centered they’re not, says the New York Times today, in Gynecologists Run Afoul of Panel When Patient Is Male, a story about Boston’s Dr. Elizabeth Stier. It seems that in her Gynecology practice she sees some men at high risk for anal cancer. She sees the condition to mirror cervical health in women, and she’s become a local expert and valuable resource to her largely low income male patients. But the OB/Gyn board drew a line and said if she treats men, she loses her specialty certification.

A quick look at the OB/Gyn Board website, and I wonder how much they know their members, or know the patients of their members. The Executive Team is all men. Of 15 Board of Directors, 10 are men. I’m not saying gynecologists must be women, but I wonder: how Patient Centered is this specialty organization? How participatory is their decision-making?

I’m reminded of a 2007 paper by Hal Sox, Medical professionalism and the parable of the craft guilds. He wrote about how important it is for medical societies (a contemporary version of craft guilds) need to put patients at a higher level than self-interested and adopt a broader code of professionalism, stating

While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.

My understanding of Patient Centered is changing, coming to be more about equal footing and a balanced distribution of power. Speeches like the one Anna Quindlen gave at the American Association of Medical Colleges, AAMC, are extraordinary and illuminate rigid, problematic mindsets today. Quindlen, prize-winning author, shared her stories with med school deans and leaders about how health professionals seem to sometimes not know their patients – leading to poor quality and experiences. What is it about Patient Centered Care that medicine doesn’t get? The irony is ridiculous: we’re too busy taking care of patients. Appointments, schedules, electronic records, pagers, phone calls, faxes, secure emails, quality measurement, performance pay, and…and…

Her speech is only available until December 3rd, posted here. (posted about this on the Society of Participatory Medicine blog)

Whether it’s about learning more about individual patients’ values and needs, or the needs of the health professionals who work hard getting to know and care for their patients — it’s where we need to move. About that, I’m Positively 4/4 Full.

NHS and VA Sharing Experiences & Ideas in Digital Health

Last week I had the privilege to meet a group of leaders, clinicians and let’s-make-the-future-now thinkers from the U.K. – part of a 3-year collaboration between the National Health Service and the Veterans Health Administration. I can’t thank the members of this collaboration enough, for being able to participate in several days of discussions, walking and dinners. A downright lovely few days.

The opportunity for this exchange is described in Making Connections, a transatlantic exchange to support the adoption of digital health between the US VHA and England’s NHS, by John Cruickshank, Joanne Harding, Jon Paxman and Charlotte Morris. The aim of the Exchange Programme is

to improve clinical engagement, develop
confidence new technologies work, increase leadership to drive digital health into everyday use for the majority of patients.

While some health politics does vary on each side of the Atlantic, both health systems provide public services for large, complex and aging populations. Through our discussions it quickly became clear that the drive for improvement and patient-centered care are shared, and the day-to-day challenges of busy healthcare teams and hurdles of coordinating care are the same. So deep dives and hands-on collaboration only serve to strengthen the resolve to meet the needs of patients and caregivers by developing and disseminating digital tools that are useful and valuable. I was particularly intrigued to learn more about how the NHS embraces patient and caregiver input into care processes. They talked about how this is a required element for their care delivery. We need to learn more about this participatory experience, and I hope someday I can observe it real-time.

I wasn’t able to join their visits to VA facilities in D.C., Baltimore and Martinsburg, VA, but coordinated a trip to Kaiser’s Center for Total Health. Director Ted Eytan (@tedeytan) and International Liaison Joy Lewis (@joylewiskp) provided a thoroughly engaging tour, touting (rightly so) Kaiser’s online reach with patients over 65%, and how they’re driving more care into the remote and digital spaces.

At that visit, Neil Evans, Co-Director of VHA’s Connected Health Office and a general internist at the VA in Washington, D.C., and I keyed in on this theme: High Touch and High Tech…Anytime.

A huge thanks to Jo Harding (@jhardingNHS), who leads the NHS-VA collaboration, has helped UK transform to new models of care and promotes telehealth for people with long term conditions through the Department of Health’s 3millionlives programme. And here’s big shout outs to all who journeyed here: Martin McShane (@docmdmartin), Director Domain 2; Victoria Corbishley, Head of Change Management; Gail Beer, 2020health Facilitator; Jane Wells, Oxleas NHS Foundation Trust Service Director; Sian Howell, Southwark CCG Governing Body Clinical Lead; Matthew Hodson, Nurse Consultant Homerton University Hospital; Eileen Sutton, Assistant Director of Urgent Care NHS London; Josip Car, Director of Global eHealth Unit; Martin Kuper and Greg Battle, Whittington Health Medical Directors; Carol Gillen, Whittington Health Director of Operations; and Helen Taylor, Whittington Health Head of Pharmacy.

I’ll end yielding the floor to our UK colleagues, with comments from their daily blog posts–

“We could not have been made to feel more welcome and the fantastic day that they had put together and willingness to share demonstrated real pride in the service that they provide to their patient population.”

“We need to be the story tellers who convince anyone who will listen that this is a must do. We know the technology has come – email, apps, telehealth – whether we want it to or not. We know the patient centred benefits it can bring, if given time and investment to flourish. We have seen the benefits to health care professionals in releasing time to care. We need to support professionals and the public to adapt, adopt and accept the new world at our finger tips. As an American President said, ‘Change will not come if we wait for some other person or some other time. We are the ones we are waiting for. We are the change we seek.’ ”

Photos are from our visit to the Kaiser Center for Total Health.
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