Category: Medicine
Realizing different perspectives to identify the value proposition for whole person care
Disclaimer: thought bubble alert – this is a bit of thinking out aloud as I work through some ideas about personalised care versus systemic change in health care. So here it goes.
Whole person care is elusive both in definition and implementation.
The definition of whole person care articulated by Hutchinson focuses on the distinction between the healthcare worker being focused on ‘curing’ the patient and ‘healing’ the patient. Yet this is only one of many attempts to address the progressive depersonalisation of medicine and healthcare. When I trained these problems were discussed in relationship to the biopsychosocial model of healthcare. Patient-centred care is probably the official term for a more personalised approach to medicine despite the parallel development of the whole person care movement. Another group refers to integrated models of care. No doubt the advocates for each of these models of care draw distinctions between their definitions and goals, and also different parties (patients, nurses, physicians, and healthcare systems) claim ownership of delivery of this care. Ultimately these distinctions do not help advance the cause at a scalable level.
The Institute for Healthcare Improvement has proposed the Triple Aim:
– Improving the patient experience of care (including quality and satisfaction)
– Improving the health of populations, and
– Reducing the per capita cost of health care
The Triple Aim provides a potentially useful framework for considering the implementation of whole person care. Whole person care does attempt to improve the patient experience of care but arguably the degree of one-on-one care suggested by whole person care is not achievable if the healing and curing is to be delivered by the same individual. Even with the growth in heatlhcare as the top employer it is unlikely that enough healthcarers could be trained and employed to provide ‘perfect’ whole person care and reduce the per capita cost of health care.
In this regard I would suggest that we view whole person care from a systems perspective and from the perspective that by introducing systemic change that is oriented to the whole person the Triple Aim could be satisfied.
In a systems approach we could hypothesise that although the ideal might be completed personalised care that there are common values, albeit with cultural variation, that could serve as the basis for interventions that effectively enhance whole person care or patient centre-care but built around change that can be made across systems rather than through training and enculturing of individuals.
Early discussion of a palliative approach may reduce unnecessary admission to intensive care, attempts at resuscitation and other inappropriate care at the end-of-life. Dignity therapy (Chochinov) can improve quality of life and reduce distress and depression. The minimally disruptive medicine approach (Montori) could ultimately translate into reduced use of face-to-face consultations or presentations to emergency care. Minimally disruptive medicine is concordant with our research which has shown that patients with a new diagnosis of cancer, who aren’t immediately terminal, desire normalcy.
So perhaps, there are values, like the desire for normalcy, that can drive system changes to improve the quality of health care but also meet the requirements of the 3rd of the aims, reducing per capita cost of health care. Values of importance could include all of the attributes of patient-centred care as described by Berwick: transarency, individualizaton, recognition, respect dignity and choice in all matters, without exception, related to one’s person, circumstances and relationships in heatlhcare.
The key in taking this approach is striking a balance in the weighting between the ‘values’ recognised by the system i.e. cost, occasions, of service, and sometimes arbitrary metrics of quality, and actual perceived quality of care as described by patient reported outcomes. The current system, specifically in relation to pharmaceuticals, but other aspects of health care, over-rewards in financial terms for small gains in cure and and under-rewards, or possibly doesn’t reward at all, any gains in healing. Health care , cannot only be defined by economic measures and so we should acknowledge that there needs to be some leeway in aligning and balancing economic value with value for the individual – it may be that we can deliver both.
Things they didn’t teach in medical school: Part 27 Managing work-life balance
OK – so many will argue that this is a topic I know very little about…and maybe they are right….or maybe, the way our patient care should be, the truth is that work-life balance should be a very individualized concept.
I know doctors that span the spectrum from their job being part-time and just enough to provide them with an income to pursue their hobbies right through to doctors, for whom, well, work is their hobby and what gives them the greatest satisfaction in life.
I think at the end of the day work-life balance is about finding satisfaction and meaning in day-to-day life and being able to recognize when you need time out from work (or life) to set a balance and recalibrate. For doctors the first step is actually leaving work but the next step is managing time away from work. The big problem for all professions in the 21st century is being ‘always on’. Mobile telephony, SMS, email, twitter, Facebook, and even pagers (remember those) mean that you can be always on. Specific breaks from these points of contact to protect yourself and your family are important – even if you aren’t very good at it (beep….the phone went off again….I wonder who it is).
Whilst I recognize the important of work-life balance of all the things they didn’t teach in medical school this has to be the least formulaic – i.e. maybe it can’t be taught but perhaps there is just advice. Such advice might be – if you have a hobby or an interest then pursue and indulge in it, especially when work is getting you down. And I can’t be prescriptive – maybe you get off on crochet with shaved armpit hair, maybe you are a nude sky-diver (not recommended), you run until you are blue and your knees rebel against your thighs, you grow poisonous plants, play the sitar or in my case listen to 365 different string quartets in a year.
Bottom line is find your own balance.
Jobs for the 21st Century Hospital & Healthcare Systems: Introduction
In Australia in 2010-11 Healthcare and Social Assistance accounted for 11.4% of employment, bypassing the retail, construction and manufacturing sectors. Around the world healthcare is a growth area for employment and it consumes progressively larger portions of GDP. The traditional hospital consisted of two types of staff – clinical staff or doctors and nurses, and support staff or administrators and cleaners, etc, etc. But staffing needs change over time. For example 30 years ago who would have said hospitals and healthcare systems would need departments of information technology and Chief Information Officers?
This post flags the start of a new series of blogs on new job (descriptions) for the hospitals and healthcare systems of the 21st century. Some of the jobs I’ll post about will include implementation scientists, behavioural economists, social media managers, big & small data analysts, molecular pathologists and diagnosticians, medical history curators, dignity therapists, disease forecasters, system navigators, and prevention strategists, to name a few.
If you think there is a new job that hospitals need then let me know through twitter @wsliauw
Things they didn’t teach in medical school: Part 26 – Giving fitness advice
Yesterday I wrote how medical school doesn’t teach much about giving dietary advice. Well the yin to diet’s yang is fitness and exercise. This is also a commonly asked question – what exercise can I do? Is it OK to exercise? Well this is important for both the sick and the well….and I’ll make a confession – I’m not one for formally exercising although my fitbit tells me that generally I do more than 10,000 steps a day.
In some cases it isn’t good to be physically active or to undertake certain exercises like heavy lifting – for example, if you’ve just had abdominal surgery you might increase your risk of hernia. Certain types of exercise – like heavy impact contact sports might be dangerous for a person with bone metastases. But in general keeping active, if not actually exercising is important.
After a stay in hospital many individuals are deconditioned. This happens very quickly with any bed rest – just like an athlete in the off-season. In this case getting back to exercise is very important for return to normal quality of life. There are simple things to do: use a chair for support to stand up between commercial breaks on television, climb back and forth along a small flight of stairs (with a railing) and take progressively longer walks around the neighbourhood (checking out their mail boxes).
Increasing exercise and fitness levels may be important in very specific conditions such as rehabilitation after heart attack or heart surgery, patients with chronic airways disease or after cancer. Increased activity after cancer may actually reduce risk of relapse and prolong life expectancy – the trials are ongoing. Frail and elderly patients may benefit from exercise to reduce falls.
The other aspect of exercise is how to do it. Recent evidence suggests that prolonged periods of exercise are not necessarily the best way of achieving fitness (and weight loss). Interval training with short bursts of intense activity may be more effective. Mixing up different types of exercise might be important for achieving different aims.
Doctors and future doctors need training in giving advice on fitness and exercise.
Things they didn’t teach in medical school: Part 25 Giving dietary advice
One of the commonest questions my patients have is “What should I be eating?”
Interestingly, I don’t think I was taught very much about basic nutrition at medical school. We did learn about the deficiencies such as scurvy (vitamin C) and beri beri (thiamine) but I don’t think we were taught much about normal nutrition. We definitely weren’t taught anything about nutrition in sickness or aberrant nutritional status. This is somewhat unfortunate as most of my patients are either malnourished as a consequence of their cancer or the treatments for their cancer. Living in modern society, most of the remaining people I see are overweight.
Now, you could argue, as the Nutrition Science Initiative does, that we don’t actually know what the ‘correct’ diet is and that most of what has been taught or is understood is wrong, or flawed, but I guess you have to start somewhere. Currently the debate is raging around whether the culprit for obesity is fat, carbohydrates or sugars, or lack of exercise. Various diets – vegan, paleo, Atkins, Mediterranean, etc – argue over the proportions of fat, sugar, carbohydrates, sugars and proteins allowed in the diet. Regardless of the best proportions the fact is that if doctors asked their patients they would soon discover that many wouldn’t know which foods contained what.
Future (and current) doctors need to be taught the best available information about dietary composition and also the behavioural techniques that have been demonstrated to assist in weight loss (or gain). Doctors also need to know how to manage the malnourished patient. Now we can turn to dietitians and nutritionists for advice this is knowledge is so intrinsic to healthcare that it should be considered essential learning. And besides….we might improve the hospital food.
Towards the minimally disrupted quantified self
One of the emerging movements in healthcare is the quantified self movements. Led by a bunch of tech-savvy self-confessed geeks the quantified self movement is all about collecting personal data and using it to inform life decisions, health care decisions and behaviour change to improve overall well-being. These life-loggers are measuring their habits, food intake, activity levels, mood, heart-rate, blood pressure, blood sugar and a host of other person-reported outcomes and physiological measures and charting them on paper or in spread sheets. Whilst this seems like a small sub-culture most people with smart phones have downloaded at least one health related app that can be used for life-logging. Persistent use is not always durable and perhaps it is because life-logging, like much other healthcare activity is burdensome. You have to spend a lot of time entering data yourself. Well maybe this is all starting to change and being a quantified self is becoming less burdensome.
Victor Montori has been advocating for minimally disruptive medicine, the aim being to reduce the overall burden of healthcare (not just the burden of disease) for patients, particularly those with chronic medical conditions like diabetes. Many chronic medical conditions actually already require individuals to include some form of life-logging as part of their healthcare routines e.g. recording blood sugar levels or blood pressure.
Smartphones and other smartphone facilitated devices are starting to enable data collection in a minimally disruptive way. For example accelerator and GPS-enabled smartphones, or smartphones linked wirelessly to other small devices like a Fitbit or a Nike Fuelband, can track exercise and other activity levels. Calorie consumption can be inferred and flights of stair counter. The same phone or added devices can be used to measure sleep patterns. Increasingly attachments to the phones can measure various physiological parameters in a non-invasive way. Apart from the occasional re-charge (they aren’t solar or movement powered yet) they are pretty much plug & play, set & forget. All you need to do is make an effort to check out the data in the form of customised reports and decide how you will act on them.
To take it a step further companies such as Soma Analytics have apps that move beyond you recording your mood directly to actually inferring your mood by analyzing your voice patterns during phone conversations. This in turn allows a calculation of your stress levels and can give you feedback and advice about stress management.
Another variation is to use the phone using the GPS tracking facility to record activity levels as a marker of a patients’ “social pulse”. For example, if an older person changes their activity patterns based on monitoring of the phone movements then this might be a sign of decline in functional status. Deborah Speaking at @TEDMED Deborah Estrin has referred to this as our “small data” and is encouraging processes to obtain this data from telecommunications providers.
All of this data can be used for personal use but uploaded to the cloud and given the right permission your medical practitioner could access the data remotely and in return provide analysis, interpretation and clinical advice on the basis of your data. Automated alerts flowing to healthcare provider or patients could be a form of minimally present telemetry.
Looking at these existing and emerging technologies one can see that having a data-driven life doesn’t need to be a full-time job even if you are collecting data 24/7/365. Even the activities which might require an effort at data entry, like recording diet or medication use, might become more automated through image recognition software or barcode/QR-code scanning. This could be continuous and uninterrupted for individuals using google glass. I think we can call this the minimally disrupted quantified self.
Things they didn’t teach in medical school: Part 23 Saying goodbye to patients
One of the things I haven’t quite got the knack of is saying goodbye to patients. I’ve recently looked after two young women the same age as myself. Both with children similar ages
In my job as an oncologist I often establish long-term relationships with patients. These relationships can span years and involve periods of fortnightly visits, stays in hospitals, and the roller-coaster ride of good and bad news. Some of these patients genuinely considered to be friends.
Unfortunately, as is the case for cancer and a lot of other diseases, the inevitable end comes. With years of experience doctors becoming increasingly good at predicting the time to end-of-life. The reality is that I know that sometimes when I am consulting with a patient, either in the rooms or on a ward, it will be the last time I see them alive or in some cases the last time I will be able to talk to them. In some cases I know they are going to hospice and won’t return.
I’m sure that the patients often know as well but nonetheless we do the dance, “I’ll see you tomorrow” or “make an appointment for two weeks”. It is an opportunity for imparting hope but a lost opportunity for saying goodbye.
In Annals of Internal Medicine (2005: 148(8), p. 682) Anthony Back offers a list of tips around saying goodbye:
(1) Choose an apropriate time and place
(2) Acknowledge the end of routine contact and the uncertainty about future contact
(3) Invite a response and use it as data about the patient’s state of mind
(4) Frame as an appreciation
(5) Give space for the patient to reciprocate and respond empathetically to the patient’s emotion
(6) Articulate ongoing commitment to care
Like most of these communication experiences it is important to practise and to remember to remember that communication is jazz – you will have to improvise.
Things they didn’t teach in medical school: Part 22 Project Management #TEDMED
Something not taught in medical school is project management. Although at medical school you might undertake assignments and similar activities, unless you are allocated a research project it is unlikely you will have any formal instruction in project management. I, in fact, don’t consider myself to be especially good at hands-on project management and work better as a collaborator on projects rather than running them directly. Project management is related to time management. You an think of time management as about managing your time to do projects and visa versa project management is a about completing tasks on time.
It is important first of all to recognise a project when it is either handed to you or you come up with the idea.
For me the simplest definition of a project is any activity that can be broken down into smaller tasks to produce an outcome which is more than the sum of the individual parts. Using this definition a project may be small e.g. preparing the meeting roster for a year or large e.g. designing a new medical school curriculum.
There are some tips for managing a project:
– really identify what the purpose and aim of the project is and visualise how the finished project will look – what are the deliverables
– estimate the resources you will need and the time you will need
– identify who is critical to your project – for example, if you need statistics advice for a research project get it early
– break the project down into the smallest tasks possible and work out what in what order they should be completed (and which tasks depend on another tasks being completed – a dependency)
– identify what will stop the project from being finished
– based on the above decide if your project is feasible or not
– identify stakeholders and collaborators
– once the project has started have a regular review process to check progress
Last night at the opening session of TEDMED 2013 Professor Rafael Yuste spoke about the relationship between pursuing big science and his passion for mountaineering. He broke them both down to 3 steps: assemble the team, map the course and keep the summit in sight. The scientific summit he plans to climb is the Brain Activity Map now known as the Brain Inititiative which was announced by Barack Obama 2 weeks ago. This is the moon project or human genome project of the decade. You can see him talk @TEDMED
Things they didn’t teach in medical school: Part 21 – you can do more than look after patients
So I don’t really like the title I came up with, after all, looking after patients is pretty important. What the title refers to is the observation that medical training equips you for more than medical practice – although nobody teaches you that.
I haven’t quite reached the point of abandoning face-to-face patient care but increasingly I spend my time undertaking activities that might be considered influencing care rather than undertaking care.
It is often observed that many people with law degrees don’t end up being day-to-day lawyers. Well this probably applies to a lot of the core professions. Last week I ran into a basic scientist who now has a job as a research strategist and commercialisation advisor.
So what is the common theme?
Professional training really consists of two themes. One is largely around the technical knowledge relevant to the discipline – i.e. the law for lawyers, economics for economists, anatomy/physiology/pharmacology for doctors, etc, etc. The second is around problem solving. Professionals/experts fundamentally have the job of correctly identifying problems and questions and then trying to solve them. In medicine my job is to ‘diagnose’ the patient’s illness, prioritise the management problems and solve them.
Now, as I sit on hospital administrative committees and company boards, my job is the same. Identify the problem and find the solution.
This week an end came to an advisory committee that I have sat on for the last 6-7 years. The advice was around eHealth and electronic decision support. Whilst I do have some understanding and technical knowledge of these areas my real contribution to the group was to look at problems from a different perspective, to re-define the problems, to re-calibrate the discussions. This was also the role of my fellow committee members who were often drawn from different professions or different versions of my profession.
Some of my colleagues and peers make a complete jump and leave day-to-day medicine altogether to pursue apparently different careers. I’m pretty sure they are out there diagnosing problems and finding solutions.
Not a good week for the Therapeutic Goods Administration and QUM
The Therapeutic Goods Administration (TGA) is charged with ensuring Australians can have confidence that the medicines and devices and other therapeutic goods that are sold in Australia and safe, effective and manufactured well. At a high level the role of the TGA is to practice evidence based medicine (EBM) and quality use of medicines (QUM). The last fortnight has seen poor outcomes on all fronts and both in the area of conventional and complementary medicines regulation.
In the first case a TGA proposed ban on combination products containing detropropoxyphene (DPP) was overturned by the Administrative Affairs Tribunal. DPP has been associated with death due to cardiac toxicity, albeit often in the situation of overdose. It is not considered to be a superior analgesic to common alternatives. Internationally the drug has been withdrawn from a number of jurisdictions because of safety concerns and available alternatives.
In the second case the vitamins giant Swisse has bypassed a ruling of the TGA that its’ diet pill does not have evidence to support its’ claims and has renamed the product and re-worded the claim. The product itself is the same. The registering process provides not oversight of this process and it can only be addressed through appeal.
Regardless of its’ best intentions in these cases the TGA seems hamstrung by the Act under which it operates. This is too the detriment of the general public and not in the spirit of the National Medicines Policy. In one case there is increased risk of harm without added therapeutic benefit, in the other little evidence of benefit. What is needed it not necessarily more onerous regulation but more thoughtful regulation and also education of the public, particular around complementary medicines.
These comments reflect my own personal opinion and not those of NPS Medicinewise.
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