Today was about people.
What I kept hearing today was that patients are people, people have goals and values, and they need to be asked and heard.
We started with Dr Harlan Krumholtz explaining that the right care "is about an informed patient, with an informed choice, based on the right information." Given the real information, a person can decide whether the potential risks or harms of some test or treatment are worth accepting, for the potential benefit of that test or treatment.
Peter Drier, an articulate non-healthcare professional, told his story about being a patient and being the recipient of a (surprise!) $117k bill from a consultant (who he never met) that spent a few hours assisting in the Operating Room. This was in addition to the original agreed upon bill for his surgery. As he told his tale of attempting to navigate a rats-nest of a system that it seems purpose-built designed to bankrupt patients, I was alarmed. Dismayed.
How could you possibly navigate this while also coping with disease? How could vulnerable patients survive in this system? How could doctors ethically accept they were a part of it?
Others in the room thought that getting a patient help to navigate the system would be a good fix. Or maybe publishing prices in a transparent way would help. Wait... what?!
I was shocked to see that people have accepted this system. Rather than challenge the status quo, they seemed resigned to work with it and plan to bodge together some work-arounds and bandaids. Incremental change is sometimes a good solution but when you have a system that toxic, how can you let it persist?
I started really worrying, worrying about the case that surgeon Dr Brian Day has before the BC Supreme Court, which if successful, will pave the way for patients to pay privately for medically necessary procedures. I try to envision a world in which this helps patients, but that future looks like the US of A, and in the US of A, health care is broken, in a far more challenging way than it is in Canada.
But, there are bright spots! In a workshop on designing the future of Primary Care, we learned about the model of the Stanford Coordinated Care Team. It puts patients at the centre and offers them multidisciplinary support to engage them in achieving health, and does so by asking team members to rise within their scope to manage care and build relationships.
Through Beyond Workups and Rule-Outs, we explored the unique drivers of care in the Emergency Room, like time pressures and fear of missing a diagnosis. We brainstormed solutions for the culture and process, and I was pleased to be able to share the (often hated in medical school but valued later in practice) "FIFE" model. This aims to aid patient-centred interviewing, to get at the person rather than the disease or symptoms:
This model forms the backbone of the Family Physician certification exam in Canada.
There were lots of other ideas about helping patients get in and out of the ER "well" and one idea for changing the culture of practice that I really like is "reverse M&M rounds" which may be the same thing as "Right Care Rounds." There was a separate session on this topic I didn't get to go to that session as there was too much simultaneous good stuff; regardless, I am inspired to attempt (time permitting) case rounds back home about inappropriate (unnecessary) care, whether it caused an obvious bad outcome or one that was a bit more subtle.
In the same vein, The Do No Harm Project presented some wonderful 'vignettes' or narratives from residents, highlighting 1) how common medical overuse is and 2) how persuasive a patient's story can be.
Tomorrow we decide how we will take what we've learned and commit to putting it to work.