Making change: The Right Care Movement

If you are reading this, you already know there is an epidemic of overuse in health care. Yes, there is underuse too, and this has been the subject of many lobbying and quality improvement initiatives to date. The medical-industrial complex, particularly in the United States, has capitalized on the fears of individuals who worry they might be victims of underuse, to the tune of billions in unnecessary and harmful "just to be sure" testing, medications, and procedures.

Of course the health of individuals and populations is primary, but we cannot discuss this in isolation, without due attention to cost and sustainability. Given the finite resources we have in health care, we can't afford to throw away the precious time of patients and clinicians, or the money of patients and taxpayers. The best way to fix either problem is to see them – under- and over-use – as one. We need the right amount of care.

Who doesn't dream of a problem in which all you have to do is shuffle the deck to solve it!? This resonates strongly with my predisposition (and tiny amount of training) with Integrative Thinking.

The classic example of two sisters splitting an orange is a good illustration of the potential of integrative bargaining, as well as its elusiveness (Follett, 1940). Two sisters both want an orange, and they compromise by cutting the orange in half. What they would have discovered had they discussed it, however, is that one sister wanted the pulp for juice, and the other wanted the peel for a cake. Discovering that they each wanted different aspects of the orange would have helped the sisters to split the orange in a way that each gets the most individual utility out of the agreement
– Kirk D, Oettingen G. Gollwitzer, PM. (2011). Mental contrasting promotes integrative bargaining. International Journal of Conflict Management, 22(4), 324-341.

This is not a traditional way of thinking. The idea that "less" can lead to "more" is not intuitive. Some examples may help to illustrate the meaning of this when applied to health:

1.By ordering fewer unneeded tests and consultations for one patient (say, to review their cardiovascular profile), the clinician can instead emphasize and support the role of lifestyle changes and free up the patient's time and energy to exercise (which will improve their health far more than any cholesterol test or drug could).

2. If a patient can stop paying for a medication she doesn't need, she has a better chance of making rent payments that month, decreasing stress and the morbidity associated with homelessness as well as reducing the chance of an adverse event or side effect from medication.

3. If one patient's MRI for a sore knee is cancelled because it was planned to assess for a meniscus tear and is not needed as meniscus surgery is not shown to be effective, then timely access is now an option for another patient who needs that MRI (perhaps they've clinically had a stroke and the CT was normal, so the pattern of pathology on the brain MRI would change the treatment plan to prevent further strokes)

It goes on. However, because many people don't think about the big picture for themselves, their practice, or society as a whole, it can be hard to convince them to consider the 'Less is More' mentality. They may only hear "less" and run screaming.

This is why we need to create a huge swell of support, a cultural shift to make the discussion about overuse and underuse the norm. Jeanne Lenzer explains more about how the Lown Institute is attempting this with the Right Care Alliance in The Backstory—Is US healthcare a frontier for a new civil rights movement?

Source: http://blogs.bmj.com/bmj/2016/05/13/jeanne...

RightCare Action Week: Get involved (LOWN INSTITUTE)

The Lown Institute is an amazing American organization devoted to transforming health care; particularly, they believe that performing unnecessary medical tests and treatments is unethical and unacceptable, and have undertaken work to empower patients and health care providers to achieve "the right care."

I had the privilege of attending their Road to Right Care conference in March of this year, and I am pleased to be able to promote the following initiative: 

RightCare Action Week

RightCare Action Week is a grassroots initiative for clinicians and others who want to take action that demonstrates how much better our healthcare system can be. 

Our healthcare system has strayed from its mission: Healthcare that is effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations.

From Oct. 18 to 24, 2015, people like you across the country will take action to show patients that we have not forgotten what good medical care is. Actions can be as simple as taking a deeper social history or doing a house call.

What can you do right now? Sign up for RCAW, vote on actions you’ll support from our growing list of possibilities, or suggest one of your own.

Here are some themes you should consider before suggesting an activity for either a single day of RCAW or the entire week.

Actions that:

·      Highlight the conflict between the healing culture and business culture

·      "Suspend business as usual" 

·      Connect patients to clinicians and clinicians to their colleagues to provide better care

·      Encourage clinicians to take as much time as needed with patients

RightCareActionWeek.org is designed so that anyone can suggest or discuss activities on the forum.

The only way to transform healthcare is if we present what better healthcare looks like. RCAW is our chance to do that. Sign up to join us now.

RCAW is an initiative of the RightCare Alliance. 

 

For more information email us at organize@lowninstitute.org or visit us at www.rightcareactionweek.org

Source: http://rightcareactionweek.org/

Day 2 of Road to #RightCare #Lown2015 Recap

This old photo came to mind as I thought about how people tell their stories:   Some graffiti at the skate park in Inuvik, NWT; Is it a profound statement about the way things are imposed on people without ever asking them or listening to them?  Maybe it's just  some teenagers upset about not having enough weed. 

This old photo came to mind as I thought about how people tell their stories:

Some graffiti at the skate park in Inuvik, NWT; Is it a profound statement about the way things are imposed on people without ever asking them or listening to them?  Maybe it's just some teenagers upset about not having enough weed. 

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.

Day 1 of Road to Right Care #Lown2015 Recap

What a great day!

Hundreds of mainly American (I am one of 4 Canadians here) doctors, patients, nurses, health administrators, and other health providers gathered today for the first of three days on the Road to Right Care Conference, put on by the Lown Institute.

Being in a room with so many like-minded individuals is invigorating but also offers hope that together, we can actually do something radical.

Main Themes:

  1. Patients and their families and advocates must be at the centre of this movement; young health care providers are the future of this and must be engaged early in their training
  2. Health care is not about consuming, being sick; most of what we do in medicine has no impact on health; health care should be about being well, and about people not diseases:
    “A good physician treats the disease, the great physician treats the patient who has the disease.”  - DR. WILLIAM OSLER

  3. Social determinants of health, especially poverty must be addressed for greatest impact:
     "I can cure homelessness. You just house them and it's cured. Completely curable problem." - DR. MITCHELL KATZ

  4. Our system must be radically transformed; we have many ideas but they boil down to the fact that HIGER QUALITY CARE leads to LOWER COST

  5. Barriers to improvement: financial conflicts of interest, profit-based systems, not listening to what patients really want (eg. independence)

  6. Things that will help us achieve RightCare: team work, communication, destroying the imbalance of power, narratives

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

My actions as a result of today:

What was missing?

  1. Emphasis on relationships between patient and caregiver. The ONLY big mention about meaningful relationships was by a Reverend B. Stanfield during his reflection at the end; the data tell us that strong relationship = better care, and less costly care
  2. Focus on patient safety. Americans talk A LOT about cost! Cost is important, but were this conference anywhere else in the world, the main focus would be on reducing harms done to patients by too much or too little medicine.
  3. Acknowledgement of this as a world-wide cultural issue. There was a lot of discussion about insurance companies, ways of paying physicians, etc. as if these financial structure problems all explain the issue; some people seemed to believe that changing the way doctors are paid – abandoning fee-for service payments – would fix everything. But, there is no system of remuneration that incentivizes good care. "Wrong care" is a problem around the world, even in socially progressive and fully public health systems. 
     

I can't wait to see what is in store for us tomorrow!

When is Medical Treatment Overtreatment? Maine Doctors Take New Look

I found a great 5 minute radio clip about Overtreatment, focussing on how healthcare providers and patients are finding the "right treatment" in Maine.

For those who'd rather listen than read, this is a great interview Patty Wright did with a Nurse Practitioner, Senior Vice President of the Lown Institute (Shannon Brownlee), the Director of a Maine Hospital Emergency Department, and a patient.

We have a lot of clinical guidelines we're supposed to follow. We sort of follow them like a cookbook. I was following them blindly, as I suppose many people do. They have no idea of the data behind it.

It's a really easy to understand and balanced summary of the problems of overtreatment.

Listen HERE!

Source: http://news.mpbn.net/post/when-medical-tre...

Lown Institute Road to #RightCare conference March 8-11, San Diego

I'm sharing this invitation to remind you to register for the Road to RightCare conference. It will be a fantastic look at how to operationalize solutions to overdiagnosis, undertreatment, and the gamut of associated problems. I'll be there too!

If that isn't reason enough, it is a great city! As I'm currently in San Diego, I can tell you that there's plenty to do in you spare time (eg. today we are renting bikes to explore Coronado Island and check out the beach; later we'll taste some great Mexican food and sample some local microbrew). 

With the holidays around the corner, we want to remind you to register for the Lown Institute third annual conference: 

Road to RightCare: Engage, Organize, Transform 
March 8-11, 2015 
Omni San Diego Hotel

Among the many great speakers featured at the conference, you don’t want to miss the opportunity to hear our dynamic keynote speaker, Diane Meier, MD, director for the Center to Advance Palliative Care, Mt. Sinai Health System. If you’ve never heard her speak on a topic of great importance to all of us, here’s a sneak peak

Dr. Meier is one of the many speakers, panelists and attendees who will be addressing our culture of medical overuse in the U.S. and proposing solutions to eliminating it. 

We’re finalizing our meeting agenda and will be sending you weekly updates. We promise that this will be the best conference you’ll attend all year. 

To learn more, see the agendaRegister now. 

. . .

Thank you for supporting and participating in our work. We look forward to seeing you in San Diego. 


Best, 
 

Vikas Saini, MD
President,
Lown Institute

Shannon Brownlee, MSc
Senior Vice President,
Lown Institute
                       

                      

Register Today! 
Click here to visit our website, review the agenda and register. 

Registration Deadline
 February 10, 2015

Providing Contraception Lowers Birth Rates in Colorado

It isn't hard to see how investing in the right care can go a long way.

How unsurprising is it to read that giving people free contraception leads to lower birth rates? I don't want to bore you but population studies like these help governments realize that intervening in health 'upstream' has cascading effects, and they are often positive.

Good health, better choices, lower costs, and less social fallout are the result of the Colorado Family Planning Initiative. They supplied intrauterine devices (IUDs) at no cost to low-income women.

Doing so decreased abortion rates, the rate of pregnancy in high-risk populations, and demand for social support programs. It also saved millions of dollars.

Speaking practically rather than politically, I cannot see the benefits of this program being outweighed by the drawbacks. The loudest objections are to things like 'the violation of parental rights' when teenagers receive contraceptive treatment without parental consent. It is my personal belief that if a person is old enough to choose to have sex, he or she is old enough to choose to inquire about and select a means of birth control.

Although pregnancy is not a "disease," it may be seen by some patients or clinicians, at some times, as undesirable or unsafe. This common-sense project demonstrates that there may be some merit in the idiom "an ounce of prevention is worth a pound of cure."

Read more here.