Nearly a quarter of a century ago (good heavens, I can hardly believe I have to say that!), when I was just starting out as a junior faculty attending, I remember one of my mentors taking me to the hospital with him on morning rounds to see all of his patients who were admitted to the hospital.
He was an eminent cardiologist, incredibly gifted and well-respected, and we walked the wards seeing patient after patient admitted with complications of multiple illnesses.
I’ll never forget, as we finished up the rounds, and sat down at the nursing station to write (not type!) his notes, he stopped, and looked off into the distance and said, “So many are here by their own hand.”
He was talking about the end stages of the diseases that were the consequences of smoking, uncontrolled blood pressure, and diabetes, poor diet, excessive drinking, lack of exercise, that led all of these patients to need to be in the hospital, with progressive diseases now going through their inexorable course.
Peripheral vascular disease requiring revascularization or amputation. Refractory angina requiring coronary artery bypass grafting. Lung cancer requiring surgery, radiation, chemotherapy. Emphysema with symptoms unrelieved by maximal medications, leaving patients bed-bound, unable to move without feeling like they were suffocating.
Knowing who to nudge the most
Having been in practice for nearly half a century (see, I’ve still got a long way to go …), this cardiologist had been with these patients for most if not all of their adult lives, and had watched many of them go from being young healthy vital people to desperate souls now seeking relief within the walls of our hospital.
Had he not tried? Had he not told them that smoking was bad for them? Had he not told them they needed to exercise, cut back on their drinking or eat healthier foods, lose weight, exercise? Had he not told them to take their medicines as directed?
Of course he had, and of course, there were countless other patients of his who had (mostly) done as he directed, who (almost) always do what we tell them, who always (often) make those healthy choices.
And certainly, there were many patients within his practice who continued to smoke, drink, eat terrible foods, who never suffered at all.
How do we know which of the patients are going to be the ones who suffer, which are going to be the ones who are going to develop the complications, and which are the 8 out of 100 or 3 out of 1,000 that deserve/require/will suffer without our maximal interventions?
Through most of medical history, we’ve been unable to know, and we’ve tried to equally apply our efforts across all of the patients. It’s likely that no matter how much new information we gain from precision medicine and learning about the genetics of disease, how much artificial intelligence and machine learning can extract from all the data, we should always continue to lead our patients to the healthiest possible lifestyles.
None of us can look at a patient — say, a smoker — and say, “This one’s going to get emphysema for sure; this one has lung cancer in their future, and I need to put all of my eggs in that one basket and dedicate every ounce of intervention I have to getting them to quit.”
Which incentives will work?
Many doctors, the best doctors, do sort of have a gestalt about who you think is going to be the one, who’s going to be the one that, if left on the road they’re already on, will undoubtedly end up with badness.
If we had all the time in the world to spend with our patients, and could be with them 24/7/365, following them around and nagging them to pass on that cheeseburger, to put down that cigarette, to get up off the couch, and we could figure out a way to do that for everybody, then eliminating all of these terrible diseases might not be so difficult.
But figuring out what we can do with what we have, in our fractured 7-minute visits, when we are clicking away at a computer screen, is a challenge that is weighing heavily on the minds of doctors throughout our health care system.
At a recent grand rounds, we heard from a health care economist how different techniques to get patients to be motivated to do things, nudges from every direction, have been shown, time and again, to just not work.
Email reminders, pop-ups in the electronic health record portal, wearable devices that nudge you to do what’s right, beeps and whistles on your cellphone, even financial penalties or rewards, seemed to do little to move our patients away from unhealthy behaviors towards what we think are the best things for their health.
Doing the right thing now for the reward of health many decades in the future, is clearly a barrier built into our human nature, and one which we as a health care team are challenged to try to overcome.
What the team can do
Perhaps there is something in the patient-centered medical home that can help move these things forward. Maybe it would help if a patient’s visit to the doctor’s office actually began before they arrive, with the electronic health record reminding them of health care maintenance items that need attention, testing they are due for, and then a way to think in advance about any prescriptions they need, any referrals they need, any forms that need to be filled out, and then a way to list out their own questions for the day.
Then, when the patient arrived in the office, members of our team would take over and start to attack them with love and attention. They would get all the administrative tasks updated, ensure that their contact information was there, enroll them in the portal, review standing orders and pre-enter information about health maintenance items — al of it done outside the confines of the time with the doctor.
Had your flu shot at a local drugstore? Noted. Mammogram done at radiology facility across town? A copy of the report will be retrieved and scanned into their record, satisfying that health maintenance field.
Still smoking? What are we going to do about that today? Ready to quit? Interested in medications, a support group, a phone app?
Data from your pharmacy showed you only refilled 70 percent of your prescriptions over the past 6 months; what can we do to help with that?
Your phone’s activity log shows you only exercised once in the past week, and have markedly decreased the number of daily steps you’ve taken since the weather turned cold. What can we do about that?
And after the visit ends, members of our team will continue to work with the patient, to go over the plan, to do teach-back, to encourage close follow-up, compliance with medications and recommended health maintenance items, and figure out whatever system works best for the patient, for that particular patient, to make sure these things actually happen.
Electronic and telemedicine contacts will reach out to the patient to find out how their blood pressure is doing on the new medicine, whether their mood is improving with the antidepressant, whether they scheduled a follow-up appointment with their cardiologist and started going to the gym more regularly.
Our hope is that ultimately all of this will add value to the care of our patients, and be able to be synthesized into a comprehensive report that helps us tease out what works best for each patient, and what might not work so well.
Because when all we want is what’s best for each and every one of our patients, sometimes it’s the little things that help turn the tide.
Or else the tide will wash us all away.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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