Jacob Reider, MD, is chief medical informatics officer and CIO at The Alliance for Better Health Care. He previously served as deputy national coordinator for health information technology at the U.S. Department of Health and Human Services. At the upcoming 2016 Oliver Wyman Health Innovation Summit, Dr. Reider will participate in a panel discussion titled “Doing Well by Doing Good: Serving the Socially Vulnerable.” He and others will explore the unique behaviors of socially vulnerable consumers and share lessons on what it takes to build lasting solutions to serve vulnerable populations. In this Summit preview, Dr. Reider asks the provocative question: Is the problem with our current healthcare system our blindness to “health” and our overemphasis of “care”?
“Shift the business models.”
“Re-align the incentives.”
These phrases are not new. Nor are the concepts they represent.
Yet we’re starting to see new experiments from the federal government, from states, and even small communities that demonstrate a new willingness to deeply engage in understanding and overcoming the barriers to true change in how we improve health.
Notice that I said “improve health.” I didn’t say “Improve healthcare.” This is much more than a semantic nuance. When we conflate care and health, we accept the fundamentally flawed assumption that in order for people to be healthy, we must in some way intervene and care for them. This assumption forms the basis of many traditions that pervade our broken system: In medical school and residency, I was taught that the individual with depression needs a medication, rather than improved coping skills. I was taught that the individual with diabetes needs a nutritionist rather than an exercise partner. I was taught that the the individual with hypertension or hyperlipidemia needed medications, regular lab work, and bi-annual follow-up visits. And I was taught that otherwise healthy adults needed an annual physical exam.
We now know that this medical education I received - as have tens of thousands of physicians, nurses, care coordinators, quality managers, hospital and health plan administrators, and government officials - is in many cases based on a set of traditions rather than science.
Consider: Marcia Angell's compelling work on our (mis)management and misunderstanding of mental illness is a sobering review of how we’ve managed to create a generation of people who are dependent on the medications that we thought would help “cure” them. Also, Zeke Emanuel has reminded us of the paucity of evidence for the “annual physical” and makes a strong case for eliminating it entirely.
Finally, the evidence for exercise as an essential component of prevention of (and management of) diabetes is well known; but when I recently asked a third-year family medicine resident what would be his choice as first-line intervention (I chose my words carefully) for a patient with newly diagnosed type 2 diabetes, his proud and instantaneous response was “metformin” rather than “exercise.”
When we conflate care and health, we accept the fundamentally flawed assumption that in order for people to be healthy, we must in some way intervene and care for them.
Maybe patients don’t need “saving” after all
These traditions, steeped in the very human need to be needed, find their common ancestor in the assumption that these people need us to get better. We sought careers in healthcare so that we can care for others. So that we can help them. We can rescue them. We can “make a difference.”
Early in my career, as a young medical school faculty member, these are the words I would hear as I interviewed medical school applicants. Help. Care. Save. I never heard the words that will form the basis of our new model of health: Empower, Educate, Witness, Listen, Learn, Share.
The genesis of the emerging model, and the new thinking and new approach to health comes from several communities – all working at the edge of public service. The edges – not the core of our system, where traditions and long-held beliefs sway thinking – are where we see the birth of true innovation.
Two social science concepts that could spur industry transformation
At the edges of our industry lie two social science concepts – two concepts that are rooted in empowerment, self-reliance, and self-determination.
Positive deviance is a social science concept that is based on the assumption that solutions to a community’s problems already exist, within the community, in the form of “positive deviants.” These individuals are able to find solutions to problems, despite facing the same challenges and barriers as their neighbors. It is rooted in nutrition research literature of the 1960’s and is based on observations that certain children are able to grow and develop adequately, despite coming from low-income, impoverished environments where a majority of children suffer from growth retardation and malnutrition.
What is different about the positive deviants, the children who develop and thrive despite the (apparent) long odds? Can we learn from them, and amplify their success by sharing their success with others? Can we empower the community to find strength and success, rather than import and impose our own views?
Of course. Over the last three decades, the Positive Deviance Initiative has used these principles to learn from communities, empower them, and facilitate better health and better lives for millions of people worldwide. The positive deviance approach differs from traditional problem-solving approaches because it depends on the community – not external sources – to identify and optimize existing, sustainable solutions to its own challenges.
Another influence from the edges is something called motivational interviewing (MI). The basis of (MI) is the same principle expressed in a joke that my dad (a psychiatrist) used to tell:
Q: “how many psychiatrists does it take to change a light bulb?”
A: “only one, but the light bulb has to want to change.”
MI reminds us that we can’t change people. People change themselves. Sometimes with our facilitation, sometimes despite our intervention. Always from within.
Both MI and positive deviance place the important emphasis where it belongs: in the wants/needs/hopes and wishes of the individual. The smoker who chooses to keep smoking will always smoke, regardless of our judgment of them.
The question for those looking to transform the health system, engage consumers, and empower individuals to live healthier lives is, can we motivate rather than judge? Can we empower rather than diagnose? Can we really listen? (Or can we at least do better than we’re doing now? This study reminds us that physicians interrupt patients after just 12 seconds.)
It’s time to abandon our traditions
Traditions have shaped how healthcare delivery has evolved in the United States and most Western cultures. Inherited from “expert-based medicine” of the 1950’s and 1960’s, the paternalistic medicalization of much of our societal challenges, and compounded by economic forces that have positively reinforced intervention over empowerment, education, and true engagement. The “patient-centered medical home” of 2016 is no more patient centered than most primary care practices of the 1990’s, despite the dedicated work of many at NCQA and elsewhere to describe the attributes of a true “patient centered” experience.
In order to break away from these traditions, we need to begin at the edges, embracing concepts like positive deviance and MI.
This won’t be easy. But we can do it. As Yoda said: “do or do not. There is no try.”