It’s December and 2014 is right around the corner. I’ve been reflecting on what I’ve learned over the past year. It’s been a bit more than a year since I launched my consultative micropractice and started blogging about geriatrics and technology. In the fall of 2012, I wasn’t really sure where any of it was going to go.
Now, as I look back on these 15 months, I see that it’s basically been a writing and learning sabbatical. (My practice is very part-time which is perfect since this give me time for writing/learning/small kids.) I’ve followed the digital health crowd and learned about tech innovations in healthcare and aging. I’ve finally learned to use Twitter. I joined a vibrant & inspiring community via the Society for Participatory Medicine.
And I’ve spent a lot of time blogging: this will be post #98 on GeriTech (a handful are by guest contributors), plus now I am writing about geriatrics for caregivers over at drkernisan.net. (I’ve stopped writing for Caring.com, but still want to write for caregivers.)
Why blog and why write? Because it’s a terrific way to do three things: a) sort out your thoughts on a topic; b) share what you’ve learned with the world; and c) engage in conversation with others interested in the topic.
In the spirit of these three things, in this post I want to share a list of the books that have influenced my thinking and writing the most over the past year. If you have a little extra time during the holidays, these are books that I’d recommend reading.
My personal goal in doing all this reading, writing, and learning?
It’s the same as it’s been since I started geriatrics fellowship in 2006:
Professional goal: to work on scalable ways to improve healthcare for aging adults, by making effective geriatric care more doable for all involved — patients, caregivers, and front-line clinicians.
To make more effective geriatric care more doable by more people, we’ll need to leverage technology, we’ll need to give clinicians the tools and working conditions to do their best work, we’ll need better systems of care, and we’ll definitely need to empower and support aging adults and their caregivers.
Wondering what I mean by “geriatric care”? I mean health care and medical care that is adapted to be a better fit for aging adults. This means healthcare that is adapted to things like increasing physical and cognitive vulnerability (usually a combo of aging and damage from chronic diseases), multi-morbidity, development of geriatric syndromes, increased reliance on others to manage life and health needs, and eventually some kind of decline and death. (The last two factors create a lot of stress on families and relationships.)
So effective geriatric care is healthcare that helps people — and their care circle — navigate these complications of health in late life. Needless to say, although older adults get a lot of healthcare, we could argue that often it’s not very effective in meeting their needs. (Read Knocking on Heaven’s Door, which I list below, and you’ll see what I mean. You probably know lots of older people who’ve been through similar experiences too.)
And now that I’ve hopefully clarified what drives me to find something interesting professionally, let me share my reading list.
Books You Should Read
Again, these are books that I thought offered valuable insights regarding how we can make effective geriatric care more doable for patients, caregivers, and front-line clinicians. In no particular order, I highly recommend:
- Drive: The surprising truth about what motivates us, by Daniel Pink. This book summarizes what researchers have learned about what motivates people, especially at work, and explains the distinction between extrinsic motivators and intrinsic motivators. It also explores what kind of work is better suited to extrinsic versus intrinsic motivators. Intrinsic motivation is great for creative problem-solving, and is fostered by autonomy over things like time, team, and task.
- Relevance: I believe that geriatric patients need a good PCP, and that the PCP needs to be able to step up and do work that is cognitively and emotionally demanding. (In this THCB post I provide specifics on the challenges of the job.) It’s hard to do this work without intrinsic motivation. Today’s front-line clinical environment doesn’t offer good conditions for this, and although teams in principle offer a lot of benefits, we are still learning how to make this an environment in which physicians thrive and can do their best work.
- We shouldn’t forget that no matter what the policy people and system re-designers do, ultimately healthcare only changes when the people on the front-line start doing different things with each other and with patients. Understanding how different forms of motivation affect those behavior changes is crucial.
- Right now many incentives affecting physicians are more oriented towards extrinsic motivation, although recently there’s recently been some interest in addressing our internal motivation.
- Astute observers will notice that I’ve traded economic security for autonomy and a more fulfilling engagement with my professional goals. (But I am only an N of 1.) You can also read this GeriTech post and this one for more of my thoughts on Drive
- Thinking, Fast and Slow, by Daniel Kahneman. Kahneman is a psychologist whose work helped create behavioral economics; his research demonstrated that people usually aren’t rational actors when it comes to economics, or really anything else. My favorite parts of this long book were the early chapters that described studies showing how people think either in a fast way (relies on biases & heuristics, doesn’t take much energy) or a slow way (deliberate, thoughtful, and much more of an effort). The book also explains how people often respond to different types of statistical information, and Kahneman demonstrates how different framing of information leads people to make very different choices.
- Relevance: This is important both in terms of understanding provider behavior and patient behavior. For providers, especially physicians in the outpatient setting, it seems to me that most are using fast thinking during most of their work time. But slow thinking seems required if one is going to do things like engage in shared decision-making, or even individualize medical care according to the patient’s circumstances. This slow thinking takes time, and depletes one’s energy. So if we want physicians to be doing this kind of mental work, how do we create the working conditions to support this?
- I have noticed that many, especially those digital health optimists, seem to think that people are usually rational actors in terms of prevention, etc. Ha. Read this book and learn more about how people do think about risk and statistics.
- Switch: How to change things when change is hard, by Chip and Dan Heath. This book I actually read in the fall of 2011, when I was a struggling medical director at a FQHC site. It was recommended to me by a very seasoned physician leader at Kaiser, and wow, it is great reading for those who want to change things. My favorite take-away is the metaphor of people being like a small rational rider atop of a big emotional elephant walking a certain path. The emotional elephant is strong and drives most of what people do and feel. The rider is rational but tires easily as it’s hard work directing the elephant, especially if you need to get it to do things it doesn’t like. To get people to change, you need to direct the rider, soothe the elephant, and think about smoothing the path as much as possible.
- Relevance: Much of making change and improvement in healthcare is ultimately about changing the behavior of those on the front-lines: the clinicians, the patients, the caregivers. In my experience, clinic leaders often give clinicians rational reasons for doing things without addressing the emotional resistances people have…or the substantial workplace impediments that make the path hard.
- I would especially recommend Switch to those people who are grousing about how doctors and/or patients don’t want to change. A more nuanced understanding of what drives behavior and how to make change easier is probably more constructive. For more on this issue, you can see the post I wrote on creating conditions for humanity in the hospital.
- Medicine in Denial, by Lawrence and Lincoln Weed. There is so much good stuff in this book that it took me a three-part series in The Health Care Blog to lay out my key takeaways. The Weeds cogently identify a number of crucial and dangerous flaws in the often idiosyncratic ways we practice medicine now. They also provide a strong critique of evidence-based medicine, and instead propose that the medical care be focused on helping patients individualize their own care. Their vision of healthcare as a more transparent, reliable and consistent system that can be navigated with independence by patients is compelling. A core concept they propose is that we should use technology and “knowledge coupling” evaluating and managing patient problems, as well as documenting it all; this would be more reliable and reproducible than our current clinician-led methods of diagnosis and management.
- Relevance: Geriatric patients are especially relevant for the Weed’s ideas. They have a lot of medical problems that persist over time, so a more reliable method of documenting and following their problems is sorely needed. And they really need individualized care.
- The Innovator’s Prescription, by Clayton Christensen & co-authors. I’m only halfway through this book but I like it much more than I thought I would. It explains disruptive innovation, which is “the process by which complicated, expensive products and services are transformed into simple, affordable ones,” and offers examples of how other industries have been transformed by such innovation (e.g. computers). It also explains why it’s basically impossible for leading institutions in an industry to succeed at this kind of innovation; instead it comes from small outsider upstarts, who start by offering a product that is not as good to a group that the leading institutions are neglecting. And of course, the book applies all this innovation theory to healthcare as it is now and as it’s changing. (Think of MinuteClinic: we docs think it’s not as good but it’s offering convenient treatment of minor urgent care problems to people who are in a hurrry or under-insured.)
- Relevance: I started this blog in large part because I believe that technology, among other forces, will be essential in making effective geriatric care more doable. Within the tech and digital health community, I hear a lot about “disruption” and “innovation” so it’s been useful learn some basic theory and history about innovation and changing established industries.
- It’s especially interesting to see physician services broken down into business models such as
- “solution shop” activities: requires creative thinking & usually charges fee-for-service (sounds like what I do!)
- “value-adding processes”: repetitive work that thrives on a good process; many surgeries & procedures fall into this, as does some chronic disease management. Because the work is predictable and process-driven, one can charge fee-for-outcome effectively.
- “facilitated network” business models: I haven’t gotten to the part of the book where they explain how this works for healthcare, but seems these are network industries that make money through membership or transaction-based fees, and the dependency among participants is the main product delivered. (Sounds like Airbnb to me, or even some of the peer-to-peer online patient communities.)
- According to Christensen, many of our current inefficiencies in healthcare are due to us mixing up these business models in a single institution (such as hospital) or a practice. Remains to be seen just how healthcare will continue to evolve and be disrupted over the coming years. (The book was published in 2009 and I’m not sure much has materially changed on the ground since then although there certainly has been a lot of activity at the policy and reimbursement level.)
- Let Patients Help, by Dave deBronkart (aka e-Patient Dave). This is not as well-written as most of the other books on this list, but it’s still a very important book as I haven’t come across anything else that concisely explains what participatory medicine is and why it’s important. This is also a good book if you would like to learn more about e-patients, and how they are trying to change healthcare.
- Relevance: Although today’s geriatric patients are unlikely to embrace the e-patient approaches en masse, I’ve been hoping for years that their boomer children would do so on their behalf, as this could generate major improvements in quality of care for the elderly. After all, we can urge front-line PCPs to modify their prescribing habits and otherwise implement geriatric approaches, but it’s quite possible that the requests of proactive caregivers will bring on changes more quickly.
- I do believe there is also a massive culture shift underway which is redefining the relationship between patients and providers. It started with the Internet providing easier access to health information and peer communities, and we are rapidly approaching a time when patients will have full access to all their health information, including our clinical documentation. The e-patients are helping spur this culture change, in which the relationship between doctor and patient will become a more balanced partnership. This is long overdue and overall to be welcomed, but it will create important changes in work of front-line clinicians, so if we are to support physicians effectively collaborating with older adults & their caregivers, we need to keep these culture changes in mind.
- Knocking on Heaven’s Door, by Katy Butler. Butler wrote a must-read NYT magazine article in 2010, titled “What broke my father’s heart.” (The meta-snippet in Google reads “How a putting in a pacemaker wrecked a family’s life.”) This book is an expansion of her magazine story. It both describes the challenges of helping her father through his last years of declining health, as well as the history of medicine’s changing relationship to death and dying.
- Relevance: This is a book about geriatrics. Reading it, you can see what it’s like to go through those last few years of life from the perspective of a family, and it really brings home just how much caregivers do, and the stresses they endure. Butler also does a good job of explaining some of the underlying history, policy, and reimbursement issues that have created a system of healthcare for elders that generally does not bring them the right care at the right time.
- We sorely need tech solutions designed to meet the most important needs of families like the Butlers. For more on this issue, see this post I wrote about Health 2.0 and wishing there was more tech to facilitate effective geriatric care.