21 December 2018
Dear Interested Readers,
Finding the Balance in Practice
I have known and respected Dr. Tom Lee, the Chief Medical Officer of Press Ganey, since he was a house officer and cardiology fellow at the Brigham and Women’s Hospital in the early eighties. He has always been one of the most outgoing and engaging physicians that I have had the pleasure of knowing. He is also a very good writer. I can’t find his first book now. It was a book of humor written under a pseudonym. His biography of Eugene Braunwald, Eugene Braunwald and the Rise of Modern Medicine, is still available on Amazon. It is well worth the time of any healthcare professional who is interested in understanding the evolution of the current moment in healthcare.
Over the years I have learned to examine the table of contents of each issue of The New Yorker for an article by Atul Gawande, and to look carefully each week at the table of contents of the New England Journal of Medicine for something written by Tom Lee. Tom’s work is always at the intersection of current practice and the future of better healthcare. In the November 22nd issue I was delighted to find an excellent “Perspectives” article by Tom and a colleague, Stacey Chang, “Beyond Evidence Based Medicine.” I have been eager to share my thoughts about this outstanding piece with you but each time I sat down to write, something like Judge Reed O’Connor’s imprudent ruling that the entirety of the ACA is unconstitutional would intervene and push my review of Tom’s article off to a later time.
I do not want to complain about politics or current events in a letter that you are likely to read during this festive season. During these traditional days that remind us of renewal and the possibility of new beginnings built on the lessons of endured experience, I for one want to think about “peace on earth and good will to all,” and have a “qualified or conditional” optimism or “determined hope” that might continue throughout the next year.
As an aside in this season of expectation and hope let me offer you a detour before we begin to discuss the paper by Chang and Lee. I recently read some refreshing wisdom in Stephen Pinker’s remarkable book, Enlightenment Now: The Case for Reason, Science, Humanism and Progress. On pages 344-345 at the end of “Progress: Part II,” Professor Pinker writes:
We don’t have a catchy name for a constructive agenda that reconciles long-term gains with short term setbacks, historical currents with human agency. “Optimism” is not quite right, because a belief that things will always get better is no more rational than the belief that things will always get worse. Kelly offers “protopia,” the “pro”- from “progress and process.” Others have suggested “pessimistic” hopefulness,” “opti-realism,” and “radical incrementalism.” My favorite comes from Hans Rolling, who, when asked whether he was an optimist, replied, “I am not an optimist. I am a very serious possibilist.”
Throughout his remarkable career Tom Lee has time and again offered us thoughtful pieces in a variety of books, scholarly articles in the NEJM, and the Harvard Business Review, that make me think that he should be labeled a “very serious possibilist” who imagines a better future for healthcare that is the logical extension of previous accomplishments and established norms and not an irrational rejection of what has worked on the basis of the latest untested “what if.”  The paper begins with a great paragraph that describes this moment in a way that should resonate with most physicians and independent practice clinicians based on their experience in practice.
Evidence-based medicine (EBM) was an important advance over the intuition-based medicine that preceded it, but its limitations are becoming clear even as it’s increasingly accepted as an aspiration. Guidelines based on clinical research are being hardwired into our operational norms, incentive programs, and information systems, and some quality measures have already been retired because compliance with guidelines is uniformly high. But even when physicians prescribe medications that have been proved beneficial in randomized trials, the chances that patients are taking them a year later are akin, at best, to a coin toss.
Chang and Lee follow that reality with what is essentially a “reason for action” that perhaps is meant to resonate with practitioners who complain of their loss of autonomy and their perceived requirement that they become an automaton that treats every patient with a “one size fits all response.” They are sensitive to the complaint of many practitioners that their ability to relate their knowledge to the individual needs of patients while in the pursuit of “productivity” denies them the joy of practice. There is an ironic implication as the paper develops that the pursuit of productivity and the slavish devotion to “evidence” and efficiency can paradoxically reduce the  value and better outcomes that are the objectives of the new era of finance expressed as “value based reimbursement.”
This gap is one reflection of the need for something beyond EBM, a model for health care delivery that can adapt systematically to the individual nuances that differentiate patients. EBM placed new emphasis on the relationship between clinical research and clinicians’ practice patterns but shifted medicine’s “center of gravity” away from the space between clinician and patient to somewhere between research and clinician. Real progress has been made, but something has been lost, and we believe it must be recovered.
As the Chief Medical Officer of Press Ganey, Dr. Lee has an unparalleled access to data about the perceptions and satisfaction of our patients. His professional responsibilities range from his own medical practice and the personal relationships with his patients in an ambulatory practice of medicine at the Brigham to a significant system wide responsibilities as the Chairman of the Board of Geisinger Health. Â His expertise extends through all of those responsibilities to his role as an editor at the NEJM, and as a professor at Harvard Medical School and the Harvard School of Public Health in Health Policy and Management. We should listen to his views and give consideration to his ideas and recommendations:
What’s needed, in our view, is “interpersonal medicine,” a disciplined approach to delivering care that responds to patients’ circumstances, capabilities, and preferences. Interpersonal medicine, as we envision it, is not just about being nice — it’s about being effective. And it could be incorporated into health care delivery with the same rigor and respect accorded to EBM.
Interpersonal medicine would recognize clinicians’ influence on patients and informal caregivers and the relationships among them. It would be anchored in longitudinal, multidirectional communication; broach social and behavioral factors; require coordination of the care team; and constantly evaluate and iterate its own approach. It requires recognition and codification of the skills that enable clinicians to effect change in their patients, and tools for realizing those skills systemically.
Chang and Lee are quick to reassure us that their concept of “interpersonal medicine” is an extension and expansion of the thinking behind evidence based medicine:
Rather than a rejection of EBM, we see interpersonal medicine as the appropriate next phase in expanding the knowledge base underlying patient care. Before the rise of EBM, experience gained from a lifetime of practice was the most reliable basis for clinical decision making, even for physicians grounded in scientific training.
Chang and Lee do not think that we have maximally achieved the benefits of evidence based medicine, but they also believe that if we perfectly followed all that we have learned the outcomes would still not be optimal. They point out that the root causes of many of the problems that patients present have social or behavioral origins that complicate management.
Although health care still doesn’t reliably use EBM, considerable progress has been made, and outcomes in many clinical conditions have improved…Yet these gains reveal that more than reliable application of guidelines is needed for the next big leaps in health. What makes us ill today (the chronic disease triad of obesity, diabetes, and heart disease) and what kills some of us disproportionately (suicide, alcohol, and drugs) are different from what ailed previous generations. The roots of these diseases are not strictly the biophysical determinants of health; they are also social and behavioral. They cannot be addressed effectively in isolated office visits or by prescribing interventions based on good science alone….Such factors are better addressed through a series of meaningful interactions focused on motivation, engagement, empowerment, conviction, and resilience…Through such interactions, relationships are built that can endure distraction and overcome hurdles.
Their reasoning certainly coincides with my personal experience and was seconded by several of the comments on the article that were published by the NEJM.
Dr. Raymond Yerkes wrote:
I am so impressed with the article by Chang and Lee. I have watched the dehumanization of medical care for 50 years…I have watched the deconstruction of the humanist practice of psychiatry with a rise of MD burnout by economic forces of “insurance” resulting in dehumanization of psychiatry .  Now I am watching the same in general medicine. The delivery of medical care must rely on relationship, community and healing…
Dr. John Clark wrote:
I could not agree more with the author’s comments… To effectively change patient’s behavior we must first connect in some way…Once we have found a way to connect, we transition to being a coach… The next thing we need is time – a good tennis or baseball coach who spends 20 or 30 minutes working with an athlete on a part of their game would never end a visit by saying “lets go over this again in 6 months”, yet we do this all of the time with patients.  Much better to have the luxury of ending the visit by saying “the things we went over today are important, but I know change is hard, so I want to see you in 6 weeks to review how we are doing with the two most important things we talked about during today’s visit….”
Dr. Clark’s comments zero in on the reality that there is a conflict between concepts of “productivity” in fee for service driven healthcare and the way clinicians are required to work in most of our contemporary systems of care. Chang and Lee suggest that team based care can be used to support the patient/ clinician relationship in a way that might convert to more time to build optimal therapeutic relationships.
These relationships can anchor our approach to many diseases, but they require a presence and capability from clinicians built on more than hard data.
It also requires systems that draw on those skills when they’re likely to make a difference. For example, at Boston’s Brigham and Women’s Hospital, where one of us practices primary care, all Medicaid patients are screened for social needs by practice assistants or medical assistants, and positive responses trigger various actions, including alerting the physician, but also bringing in community health workers and others. Though these concepts are not new, they have not been instituted systematically in most organizations.
…The fee-for-service reimbursement system emphasized delivering evidence-based care efficiently, but new value-based models of care prioritize effectiveness over throughput…
The authors do more than suggest that we focus on relationships in addition to evidence based practice. They give us a high level cascade of four steps that would support the transition to “interpersonal medicine. “
The key steps for making interpersonal medicine reliable can be adapted from the rollout of EBM in health care.
- First, it has to be taught. One danger is assuming that clinicians already have the skills to deliver interpersonal medicine as individuals or groups. The educational process requires building innovative, practical curricula and new tools that emphasize experiential learning for skill acquisition.
- The next step is measuring processes and outcomes, which requires agreement on metrics or appropriate surrogates. The research underpinning EBM suggests that “soft” outcomes are often the important ones and can be measured rigorously even when they’re variable. If trust is the foundation on which clinician–patient relationships are built, for example, we have work to do in measuring it. Because improvement is important, measurement should be done in real time so that clinicians can respond nimbly, and the outcomes from multiple perspectives (such as patients, families, and other clinicians) should be captured.
- The third step is enabling interpersonal medicine, which requires developing matchmaking protocols that predict stronger relationships, so we can pair clinicians and patients for success, creating environments that reduce anxiety and foster interaction.
- The final step is creating incentives for interpersonal medicine, both financial and nonfinancial. This step is fraught with political hazards but could accelerate improvement. It requires rating and benchmarking clinicians on the basis of outcomes, relationships, and understanding and moving beyond productivity as a primary value indicator…Ultimately, transparency is the most effective way to celebrate and recognize humanistic skill in parity with scientific accomplishments.
Perhaps because they are anticipating some push back, and perhaps because they realize the “political” nature of their suggestions, and the reality that all suggestions for change or modification in a social system that has been vulnerable in transition for decades meet resistance, Chang and Lee finish with a statement of accommodation and reassurance.
None of these elements are unattainable: some solutions have already been proposed and (inconsistently) instituted, if not in medicine, then in adjacent or analogous fields. This effort is not about addressing lack of knowledge, but about building systemic capability at a scale that mirrors our scientific effort. We can pursue an empathetic version of medicine that embraces emotion and appreciates behavior if we value human nature as much as human biology.
The authors’ expectation of pushback was validated by a comment from Dr. Mark Jewell:
I am troubled by this article in terms of its embracing belief-based interpersonal medicine. Is this not some variation on the Kavanaugh Standard which holds that any decision requiring a deliberative consideration should be decided on just one thing: belief?
Patients often have erroneous beliefs about their health and wellness that cannot be substantiated. If physicians go along with the tenets of this article, and make credible these erroneous health beliefs that are not evidence-based, we enter into a folie a deux situation.
I disagree with Dr. Jewell. I do not think that Chang and Lee suggested that we accept every erroneous belief that a patient might bring to the office. They were also not suggesting that we embrace notions of treatment that have no basis in science or vary drastically from best practices as a way of building a relationship with a patient. They advocate a relationship with the patient that builds trust and recognizes that there are social and behavioral factors that we often ignore as we prescribe solutions to people that we really do not know or understand at the human level. One size never fits all. I do not know about your experience, but I do know that there is a range of potential outcomes from any therapy. My bias is that trust is critical to compliance and compliance effects outcomes. I believe that patients who have a trusting relationship with their providers have better compliance and outcomes. The authors go to the literature to make that assertion.
Not surprisingly, better physician communication is associated with a 19% gain in patients’ adherence to recommended therapies and improvement in a variety of outcomes.
I’ll give the last word to Dr. Alejandro Quinonez who was thrilled by the way his method of practice seemed to be celebrated. He wrote:
Yes! that’s why the family physicians have had a special roll for a long time.- After practicing medicine for 33 years, I have treated grandpas, fathers, sons and grandchildren of entire families and know about their health conditions with exactitude and precision; besides giving them the best choice of treatment or referring them in a correct way to solve the problem at the right time.- The key to get success in all that process has been the “confidence.” That is a kind of an interpersonal relationship that systematic massive health processes, sophisticated and expensive technology developers and the economy managers appear not to understand very well yet.
Positive change is a continuous process built on measurement of outcome and analysis of the result against the desired objective that results in further modification toward perfection. You know the PDCA cycle. Lee and Chang don’t reject evidence based medicine, but they sense something is missing and know that improvement is possible. I totally agree with their call for a new emphasis on interpersonal relationships and hope that somewhere within the current cacophony in healthcare we will find a way to test their ideas and suggestions.
The Darkest Hour Has Passed
The calendar finally says that it is winter. Today is the warmest day that we have had since late September. Go figure. Winter has begun in my neighborhood with a mini heatwave and heavy rain that will surely wash away much of the thick snow cover that we have had from before Thanksgiving.
Today’s header is a picture of the back side of “Shadowlawn Farm.” I took the picture last week during one of my regular walks. It was a very cold day that was remarkable for a bright blue sky with the total lack of clouds. You can’t feel the cold from the picture, but the temperature was below twenty degrees. Yesterday was equally clear and beginning to warm up so I took a few more pictures of this lovely site. Below is a demonstration of mutual tolerance and curiosity from three of the farm’s residents.
When the rain ends I hope that we will still have enough of our snow left to allow us to credibly say that we are having a “sort of White Christmas.” My grandsons are arriving from California on Sunday with hopes of trying out their snowsuits while sledding and sliding across the frozen surface of the lake. I hope that they will not find that all the beauty of winter has turned to puddles. The one positive thing that even the “heat wave” can’t change is that we have already had our shortest day and longest night of the year.
Over the next week or so we will all celebrate in our own way, and within our own traditions, the Winter Solstice and the New Year that begins in its aftermath. I want to wish you peace, happiness, opportunity, and the hope that our world is learning lessons everyday and making slow but steady progress toward justice. I am grateful for all that you do each day to improve the health of those in your community and move us forward toward the day when the Triple Aim is our shared holiday gift.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
