I came out of the talk thinking they should rename their Great Challenge:
How Coaching and Lifestyle Modification Can Prevent Diabetes, Obesity, and Cancer, and Can Also Help Manage Diabetes.
Because those were the main topics discussed, and also seemed to be the primary domain expertise of the Challenge Team.
Now, these are indeed worthy topics of great population health importance.
However, such a focus marginalizes the millions of Americans who need much more than coaching and lifestyle modification to manage their chronic diseases. It also offers little help to those of us -- clinicians and caregivers -- in the trenches who are struggling to help these patients with their complex health needs.
Another disappointment is that the discussion didn't really address the challenges of managing multiple chronic diseases, also known as"multimorbidity". This is unfortunate, since managing chronic diseases becomes a different -- and harder -- ball game when people have several of them. (Here's one review of the evidence.)
This is especially true when people are older and frailer, or if they have cognitive impairment (which seriously impairs their ability to self-manage their chronic conditions).
And as any primary care provider can tell you, there are *lots* of people out there with multiple chronic diseases. The UpToDate chapter on multimorbidity (which relies in part on this report) lists the following fun facts:
- Estimated 1 in 4 Americans have at least two chronic conditions
- Estimated 2 in 3 Medicare beneficiaries aged 65+ have two or more chronic conditions,
- Estimated 1 in 3 Medicare patients has 4+ chronic conditions
"Multimorbidity is associated with staggering healthcare utilization and costs. The two-thirds of Medicare beneficiaries with multimorbidity account for 96 percent of Medicare expenditures."
Doesn't this sound like a Great Challenge to you?
Well, it seems this is not the Great Challenge TEDMED has in mind. This Great Challenges team was very strong on prevention and lifestyle modification, had a strong patient advocate (a younger woman with Type I DM), but had precious little advice on managing scenarios like the one I describe in this post.
What to do when a person with diabetes, high blood pressure, arthritis, glaucoma, and eleven medications comes to the visit, where we discover uncontrolled blood sugar, too high blood pressure, falls, urinary frequency, anxiety, trouble managing medications, and social isolation?
This is managing chronic diseases as many of us experience it. We could use more innovative brainstorming sessions to work on solutions.
The TEDMED panel on the question I didn't ask
Here is a question that was mistakenly attributed to me -- in a twist of cosmic irony, TEDMED identified me as the author of a question that I would literally *never* ask -- followed by the initial answer provided by Dr. Micheal Roizen, Cleveland Clinic's Chief Wellness Officer:
Q: "What do I do with patients who are resistant to any kind of help with their chronic illnesses, and with behavior change related to that? How do we convince patients who are resistant to treating his or her chronic disease?"
A: "The only ways are either educating them about what is important, or incentivizing them strongly." (See the rest of the answer here; the details include coaching, environment modification -- get the Chips Ahoy out of the room -- and a nice $2000 bonus for those patients who succeed).
Dr. Roizen goes on to say that 63% of their patients with chronic disease have transformed. This is a nice result. But I doubt you'd make much headway using that approach with older patients suffering from multimorbidity.
Why? Let me start by answering the question that I didn't ask.
What, in fact, do clinicians like me do when we come across older patients who are "resistant to help with their chronic illnesses"? Here's what I do:
- Assess for cognitive impairment. Before I start "educating", I look into underlying reasons for why the person can't manage their health care, or otherwise isn't following through on the care plan. In older adults, cognitive impairment is often discovered, once one looks. (Early dementia and medication side-effects are the most common underlying problems that I find in the outpatient setting.)
- Try to figure out how the patient and family see the illnesses, in order to understand what's interfering with their ability to address the illnesses. Common things that turn up include:
- Financial problems getting the medications
- Overwhelmed by too many medications, by too much complex medical care in general, or by caregiving demands
- Skepticism about allopathic medicine or other doubts about our conventional proposed approach
- Misunderstanding how serious the illness is, or how treatable it might be
- Substance (ab)use
- Low health literacy
Now, I'm not against lifestyle changes and behavior modification. My goal, and I know this is the goal of many PCPs and geriatricians, is to figure out a mutually agreeable, and feasible, plan to help the patient with his or her health. Often this includes coaching on lifestyle (if I can help them get it) or environmental modification (if feasible).
But a lot of it is figuring how to help patients follow-through on conventional medical management. Like picking one or two generic medications to focus on (a good opportunity to talk about what's likely to bring the patient the most bang for their buck). Or picking a symptom to focus on managing. Or sitting together to review what the specialist said, and putting it in light of the patient's overall health condition (and other chronic diseases).
The TEDMED panel on geriatrics and chronic disease
Another illuminating question and answer: here is the geriatrics-related question I had submitted via Twitter:
My Q: "So much chronic disease occurs in geriatric patients. Why aren't there more resources targeted especially towards the elderly, or those with dementia?"The question was directed to Dr. Dileep Bal, a public health officer from Hawaii, and you can view Dr. Bal's answering the question here.
He gives a long detailed answer focusing on -- surprise surprise -- prevention and wellness. He says the "focus needs to be in keeping them well, especially for elderly population. Fifty percent of our health costs are related to people in their last year of life. So I think both from a financial, and from a lifestyle point of view, specially for the elderly, you need to focus on how do you keep them healthy."
He also says "Keep the well elderly well at home, before they show up in my clinic." He goes on to describe a program of preventive care including senior centers, exercise programs, and systemic dietary interventions (like limiting soda and fast food availability). He mentions people in their 90s participating in exercise programs, and the need to modify societal cues (McDonalds is mentioned).
Another physician on the panel, Dr. Deneen Vojta (whose bio highlights extensive experience in diabetes prevention and management) offered a different perspective. She noted that older women commonly do not list exercise and healthy eating as priorities, but rather care about their finances, friends and family, and staying in their home.
True that! Then Dr. Vojta goes on to describe how lifestyle changes should be framed as ways to achieve those above priorities. She doesn't address how patients suffering from very symptomatic chronic conditions, such as heart failure and COPD, can be supported in making these lifestyle changes (hint: for many, it requires medication optimization so they can be more active).
Sickcare versus health education and coaching
One part of the talk that did resonate with me was when Amy Tenderich pointed out that as our healthcare system is really a "sickcare" system, it's problematic to ask it to be responsible for prevention. She suggested that we might consider adding another arm to the system, which would focus on health education and coaching.
I like this idea. However, for those patients who are older and sicker, education and coaching needs to really integrate into their "sickcare," both by helping patients navigate the sickcare system, and by taking their various diseases into account when providing health education and coaching.
For instance, I've seen many older diabetic patients develop mild dementia, and struggle with their diabetes care. They need help figuring out simpler and safer strategies for their diabetes. However, many diabetes educators don't seem prepared to problem-solve around mild dementia. (Or perhaps they just don't notice my writing "suspect mild dementia" in the referral? Would earlier definite diagnosis via brain scan help?)
Is TEDMED's panel missing a key point of view?
I found myself wishing TEDMED had included an expert able to really discuss managing multiple chronic diseases in primary care, such as Ed Wagner, who pioneered the Chronic Care Model. (This commentary by Wagner on chronic care management addresses multimorbidity and person-centered care, and is a really fantastic read for those who have journal access.)
They could've also considered someone particularly focused on the unique needs of older adults. I might nominate someone like Cynthia Boyd, a geriatrician who has published fantastic articles on multimorbidity and on Guided Care, a program that help older adults manage and coordinate the care of their many chronic conditions. (Her 2005 JAMA article on what happens when you try to apply clinical practice guidelines to a typical patient with multiple conditions is a classic. She also co-authored this very good 2012 JAMA commentary on designing healthcare for multimorbidity.)
Last but not least, although I'm disappointed in the way that the TEDMED talk skewed towards prevention and lifestyle, I can't say that I'm surprised. Much of what I've come across these past few months, as I've been learning about healthcare innovation, is skewed towards younger, educated people who either want to prevent disease, or are heavily invested in the management of one particular disease.
This despite the fact that the experiences of older adults drive most healthcare spending, not to mention the impacts on these patients and their families.
In a nutshell
Older adults and those with multiple chronic illnesses are two very large, important, and challenging populations to care for. Improving chronic disease management for these groups is essential, both for the sake of the millions of patients and families affected, and because this group drives the bulk of national healthcare spending.
TEDMED's team for "Managing Chronic Diseases Better" seems to have special depth and expertise in the prevention of chronic disease. Their recent videochat largely focused on healthier lifestyles, coaching, and prevention, and had very little on the crucial challenges associated with managing -- not just preventing -- multiple chronic illnesses. They also had little to say about the ways that chronic disease management often should change to meet the unique needs of older adults and their caregivers (such as adaptations when patients develop cognitive impairment). Conditions such as heart failure and COPD weren't discussed.
I'll end by quoting the intro to the 2012 JAMA commentary cited above:
"The most common chronic condition experienced by adults is multimorbidity, the coexistence of multiple chronic diseases or conditions."If TEDMED wants its Great Challenge to be relevant to really making management of chronic diseases better, I hope they will find a way to address older adults and multimorbidity in future events.
For more of my take on TEDMED's Great Challenges so far, see this post about the Great Challenges overall, and this post about last month's videochat on caregiving.