Co-authored by Jennifer Mieres, MD, FACC, FASNC, FAHA, Sr.Vice President, Office of Community and Public Health Chief Diversity and Inclusion Officer North Shore -LIJ Health System
While working and sharing stories during the production of the PBS documentary RX: The Quiet Revolution (directed by David Grubin and airing on WNET on June 23rd), one particular anecdote, the story of "Mr. R.," came to our minds. At 64 years of age, a cardiology team had just saved Mr. R.'s life after he suffered a heart attack which left him with 40% of his normal heart function. He visited the clinic every month for follow-up and was improving well until, about six months after his heart attack, seemingly without cause, he was readmitted with heart failure. The team treated him again, and eventually sent him home. However, on the day of his discharge, the nurse taking care of Mr. R. shared with a physician that Mr. R. had confessed that he had a new girlfriend and had stopped taking his heart medications because they impeded his ability to be intimate with her. Mr. R. was afraid to disclose this information to his care team. By focusing so intently on making a diagnosis and creating a treatment strategy, the team had failed to understand what mattered to Mr. R., and thus failed to engage him in crucial decisions concerning his health care.
Much of the (often rancorous) public debate on health care has focused on how it gets paid for. But now is the time to consider how we want our health care systems to actually look, feel and provide for us. Chronic diseases (like diabetes, high blood pressure and coronary artery disease) account for 75% of total health care costs and the majority of deaths in the United States. But there has been little change to an approach to care that evolved historically to treat mostly acute problems, like infectious diseases and complications of childbirth. Engaging and empowering patients and families as partners, and whenever possible, leaders, in their own health and health care must be the central consideration in developing new models of care.
Mostly under the radar, providers and health systems around the county are beginning to take it upon themselves to put patients in the drivers' seat and re-invent health care delivery. These health systems are discovering solutions that are dramatically better for everyone than the current norm. Grubin has chronicled this "quiet revolution" in his new film, Rx, by profiling four innovative programs in Maine, the Mississippi Delta, San Francisco, and Alaska that are tackling the epidemic of chronic diseases.
There are common threads that run each of the four distinct care models. In different ways, each is trying to break out of the reactive, transactional, biomedical mold that has typified traditional approaches to health care. Each program is taking a team-based approach that elevates the roles and responsibilities of non-physician providers - a model that works particularly well in chronic disease management, by limiting the physicians' role to dealing with the complex questions of diagnosis and management for which they are uniquely trained. Finally, each approach prioritizes the human relationship between patients and their providers as paramount to excellent, effective, high quality care.
If these new approaches are so much better for patients and providers alike (and are also more affordable!), one might wonder why the changes haven't diffused more broadly and quickly. Truly engaging people as partners in their health requires profound cultural and organizational changes, including a significant transfer of power from the current incumbents (particularly doctors and hospitals). Redistributing this power will surely necessitate a complex change process. Medical school curricula must be dramatically redefined and re-centered on the patient, a subject which Grubin investigates in RX: Doctors of Tomorrow, an accompanying piece to The Quiet Revolution. Practicing doctors need to learn new skills that involve changing how they work with and relate to patients and teams of other health care providers (which is why it is so exciting that the American Medical Association was the lead sponsor of Rx). And patients will need to not only demand a very different type of service, but also be prepared to engage much more actively in decisions and actions related to their own health and health care. The revolution so far may have been quiet, but it's time to turn up the volume.
Contributed to by Christopher Perry-Coon, MPH