participatory medicine

Paul Levy, the former CEO of Beth Israel Deaconess Medical Center in Boston, put up a post last week saying that the Triple Aim – improving population health, improving the experience of care, improving per capita healthcare cost – was poorly aimed, and totally missing its “make healthcare better” mark. It’s a chewy, tasty read, with an even chewier and tastier thread of comments.

The money shot for me: “the real battles over power, money, customer choice, and cost” are indeed still happening far, far away from the point of care, and compromising the patient’s experience, the community’s health, and the ability to control spiraling costs. Of the three legs of the Triple Aim stool, the cost piece is the biggest barrier to its implementation.

Can you think of any US industry that would willingly transform itself outta $1T+ in revenue per year?

That’s the ultimate economic outcome of the Triple Aim, and I can hear and feel the resistance of the medical-industrial complex to ending their arms race toward “market dominance” via daVinci systems, proton beam facilities, soaring marble lobbies, and equally soaring temples full of hospital beds … when what we really need is hundreds (thousands?) of small clinics across the landscape helping people get or stay healthy via great primary care, not tertiary hospital resurrections.

Payers and big health systems, EHR vendors, policy wonks all negotiate over the patient’s supine form (and the heads of most clinicians, to be fair) to determine how to divide up the $3T+/year their arms race serves up.

Do we have a prayer of Triple Aim in this landscape? I dunno, but I’m fighting a ground war alongside my patient-side band of guerilla compatriots to see if we can drive some revolution from the grassroots. ‘Cause the folks in suits ain’t moving fast enough toward change.

Spending one’s days on the advocacy beat out here on the Wild Wild Web can be hugely rewarding. Like, say, when you start getting recognized by organizations like the WHO as a strong voice for people-who-are-patients.

Then there are the days when you get called f***ing a**hole by strangers for simply speaking up.

This is not a unique problem for patient advocates – this happens to anyone who speaks up in service of changing a cultural norm. Just ask MLK, who was trolled by none other than the FBI, who told him he should just kill himself. Imagine the fun the FBI could have had on Facebook, if MLK vs. FBI on Facebook had been a possible-thing in 1964.

It can happen in the e-patient game, too, as shown in the Bill Keller/Emma Gilbey Keller/Lisa Bonachek Adams/NY Times dustup over whether or not patient blogs, particularly those about cancer, are TMI (Too Much Information – translation: “ew, gross”).

Just being a woman online (guilty as charged) can be enough to draw the gimlet eye, and ire, of a mob of trolls. The #gamergate mess – if you click that link, pack a lunch, a raincoat, and some serious antibiotics – is an example of that.

I recently tripped over a compelling piece on the Guardian’s site. The piece, by Lindy West, was about how she had been hard-trolled by someone who had gone so far as to create a Twitter handle that mimicked Lindy’s recently dead father, who she grieved for deeply. And who used that Twitter handle to troll her about her stance on rape threats.

My dad was special. The only thing he valued more than wit was kindness. He was a writer and an ad man and a magnificent baritone (he could write you a jingle and record it on the same day) – a lost breed of lounge pianist who skipped dizzyingly from jazz standards to Flanders and Swann to Lord Buckley and back again – and I can genuinely say that I’ve never met anyone else so universally beloved, nor do I expect to again. I loved him so, so much. ~ Lindy West

Lindy West is no stranger to the experience of being trolled. She’s a prolific, funny writer who’s talked openly about being a fat girl at the gym, about the toxicity of the “men’s rights movement,” about sexuality, about comedy … the girl’s got content. And trolls love to gang up on women on the web.

So put yourself in the place of a young woman, who recently lost her beloved dad, who suddenly finds a stranger co-opting her dad’s name and image, and then aiming threats of physical violence at her via the handy-dandy trolling tool known as The Internet.

What made this piece stand out was the payoff – after she shared on Jezebel.com how much this Twitter troll had wounded her by making rape jokes, and threats, using a handle whose avatar was a photo OF. HER. DAD. … she heard via email from the troll himself. I won’t put any spoilers here, because I want you to read the piece yourself. And maybe even listen to the recent This American Life episode that features a story about Lindy + the Troll.

My point? I think Lindy’s right – feed the trolls until they explode. Advocacy requires disturbing the status quo, which risks some serious pushback from those who are in that status quo’s driver’s seat. Ask any woman who’s blazed a trail outside “the woman’s place” – Boudicea, Susan B. Anthony, Golda Meir, Dr. Elizabeth Blackwell – what it’s like to take on the boy Mafia status quo. Push for change, and be aware you’ll need all the ordnance you can muster.

Because what the haters really want is for us to shut up. What trolls want is our silence. We have to meet that with a serious, and steady, “THAT’S. NOT. OK.” chorus.

Guess who got invited to WHO? No, really.

The World Health Organization (WHO) invited yours truly to its First Global Experts’ Consultation in service of building a WHO framework for patient and family engagement. This is all due to my part in the ongoing anvil chorus that is the new Patient & Family Engagement Roadmap, developed by a group of dedicated folks from all parts of the healthcare compass over the last couple years, with funding from the Gordon & Betty Moore Foundation.

I spent just over two days in Geneva, most of the time head-down in discussions about how the global health system – a patchwork of services delivered by an even patchwork-ier cadre of healthcare delivery systems – can better serve the needs of the people/patients who seek medical care and health information from them.

This post will not attempt to report everything I saw/heard/thought/felt in that jam-packed 16 hours of ideas and outlooks. What I’ll share is my perspective on the challenges, the opportunities, the pitfalls, and the hopes that – in my view, at least – emerged during that lightning round of global spitballing.

CHALLENGES

There’s an old joke that asks, “What’s an elephant?” The answer: “A mouse designed by a government committee.”

That’s the risk, and challenge, to any attempt to build a definable set of standards for a human effort. Education, transportation, trade, infrastructure, communication, medicine – all require some sort of standardization to make them useful to more than one or two people huddled over a campfire. A study of history will show that as much as we humans are great idea generators, trying to get the rest of the tribe to adopt our new idea isn’t easy.

The father of quantum mechanics, Max Planck, said it best: “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.” To paraphrase: Science advances one funeral at a time.

Medicine, which has been practiced for millennia by magical beings initiated into secrets of “science” that could not be understood by the common human, has only become understandable to the average Joe and/or Jane as public education has become available across the globe. Public education still isn’t available everywhere, and the character and content of that education can be complicated by cultural views of science, of the education of women, and other factors that impact access to information.

So the challenges I see here are two-fold:

• Calcified thinking in power structures, both scientific and political.
• Lack of science education and information access in the wider population.

That’s true in developed nations – just witness the “science denial” movement in the US that stubbornly insists on not being confused with facts on issues like climate change or human reproduction – as well as in emerging nations that are still building basic infrastructure.

OPPORTUNITIES

Well, let’s start with who was in the WHO-room. Clinicians, policy wonks, and healthcare advocates from Uganda, India, Canada, Ecuador, Pakistan, Saudi Arabia, Belgium, Ireland, the UK, the US, Switzerland, the Netherlands, Thailand, Australia, China, and Malaysia, along with a wide array of WHO folks from their Geneva HQ as well as a robust representation of their Western Pacific Region Office (WPRO). WHO’s Envoy for Patient Safety Sir Liam Donaldson (that link is to his Twitter feed, which I highly recommend) was actively engaged in every part of the discussion over the two days, and I was deeply encouraged by his clear insights into the issues we’re all wrestling with in transforming the global healthcare system.

The story that had the biggest impact on me was the one told by Dr. Jonás Gonseth, head of Hospital de Especialidades in Guayaquil, Ecuador. His experience was one that I think spotlights the core problem: lack of trust in the care delivery system by the people that system purportedly serves. I wish I had a link to the video he shared, which clearly showed the lack of trust that the Ecuadoran people had in their healthcare system. Demonstrations outside the hospital, intercut with a number of clips that included a patient on a gurney being rolled toward the hospital door who got dumped on his head when the gurney tipped over as the dweeb hauling it couldn’t figure out how to get it over a curb … you get the picture.

Dr. Gonseth was asked (begged?) by the President of Ecuador to tackle the mess that was the Guayaquil Hospital de Especialidades. In just over two years, he’s worked what could be called miraculous change in quality improvement and patient safety, largely by advocating for community social participation in that work, and for patient empowerment. He’s transformed the culture inside the hospital, and the level of community trust in the care delivered by that hospital. The money quote: “It was such a disaster we had nothing to lose [by involving patients].”

What that story told me is that grassroots frustration with healthcare systems is a global issue, one that was made clear by all the from-the-ground presentations over the two days. That leads me to the opportunities here, which are shared by both developed and emerging countries:

• “Start where you are. Use what you have. Do what you can.” That quote from Arthur Ashe makes it clear that any – ALL – of us can work on healthcare system transformation. So let’s get this party started.
• Transformation does not happen from the top down. There does need to be a leader, but a successful leader will more likely come from outside the system needing the transformation.

That calcified-thinking challenge I mentioned above presents a solid opportunity to those of us on the ground, working to transform the system. Designing from the outside in is a software development approach that focuses on satisfying the needs of the end user. Healthcare systems *must* look at system transformation from that perspective: start with the people you’re serving, not with the folks running the hospital/professional society/medical association. The people being served – THE PATIENTS – are the end-user stakeholders.

PITFALLS

There’s much inertia confronting transformation of a massive human system like healthcare delivery. It’s exhausting if you look at it as a “system,” but since it is a system, any action has to be considered in the context of what sort of dominoes – or dynamite – that action might trigger. Plus, attempts at transforming bureaucratic process lead to what I’m going to call Donaldson’s Dictum (in honor of Sir Liam Donaldson, who said it): “Ability to simplify bureaucratic complexity draws heavy fire from the bureaucrats who create that complexity.”

And then there’s the elephant in every room: the money. Whatever the economic basis is for the healthcare delivery system in question, getting quality improvement and patient safety into the budget is a daunting task. Dr. Jonás Gonseth effected his hospital transformation in Ecuador without any increase in budget, but I wonder how much heavy lifting he had to do to sell his ideas to the bureaucrats? Since he’d been asked by the country’s President to take charge and fix a major mess, that might have gotten him through the first week. But transformation at this level takes months and years, so figuring out where the money’s gon’ come from is critically important.

So, in short:

• Is there a budget for real system transformation?
• Is there enough political will to allow that transformation to occur?

HOPES

When it comes to complex systems thinking, I’m a simple creature. I believe that the more complex the system you’re looking at gets, the more you have to go right down to the molecular level to regain perspective.

If you’re trying to end a disease like polio, you have to start where Jonas Salk did: with the virus itself. If you’re trying to create a healthcare system that delivers human health, you have to start with … the people who are seeking health care. June Boulger, Ireland’s National Lead for Patient and Public Involvement in Healthcare, said the overarching message of her work is “people helping people.”

When I took the mic to make a comment on Monday afternoon, I told everyone in the room to run right back to the ground level whenever they got too “system”-y in their thinking or their approach to quality improvement, delivery improvement, and/or patient safety.

Design from the outside in, begin with the end in mind, “start where you are, use what you have, do what you can,” lather, rinse, repeat.

That’s my entire philosophy of healthcare system transformation in one sentence.

Let’s get this party started.

Res ipsa loquitor: