And this year, there was a special emphasis on promoting a “Culture of Health,” a meme that has become a centerpiece of the Robert Wood Johnson Foundation’s work.
So much so, that when I approached a conference speaker, to briefly comment on my interest in helping beleaguered family caregivers with their carees’ health and healthcare issues, I was advised to work on promoting a culture of health.
Hm. Funny, but as a generalist and geriatrician who focuses on the primary care of older adults with multiple medical problems, I’d been thinking more along the lines of:
- Promoting the wellbeing of older adults and their caregivers.
- Optimizing the health – and healthcare — of my aging patients.
As in: “I care about how you are doing, and I will provide care to help you with your health.”
Since all my patients have multiple medical conditions, that care means finding ways to help them with their many health concerns. These include diseases, such as diabetes, COPD, heart failure, and Alzheimer’s, as well as “problems,” such as pain, falls, depressed mood, and worrying about whether some recent snafus are a sign of dementia.
It even includes issues like tense relations with anxious children who think Mom should move to assisted living; a common “relationship issue” that inevitably tracks back to the present and future state of Mom’s underlying health problems.
My work, as a doctor, is to collaborate with my patients in order to minimize symptoms, maximize function, improve wellbeing, and prevent health complications. All of which, if I do it well, generally ends up helping their family caregivers.
Is promoting a #CultureofHealth the same as promoting a #CultureofCare? As a front-line clinician, they feel very different to me.
Namely, one strikes me as about working way upstream to prevent health problems before they happen. (“We shouldn’t need a sick care system!”)
And the other is about responding to people who are suffering, and need our help to feel better. No, this is not the hallowed work of preventing chronic diseases from emerging. But it is preventing – or at least delaying — further deteriorations in health and function. It is helping people make the best out of the situation they are now in.
If you are working with people who are already downstream, and are coping with the burdens of chronic illness, should your priority be #CultureofHealth? Or #CultureofCare?
Consider, for instance, the family described in Knocking on Heaven’s Door. If Katy Butler’s parents, struggling with cognitive impairment and progressive decline in the aftermath of a stroke – and this after a lifetime of “healthy living” – ask their primary care doctor for help, is he more likely to offer the right assistance by thinking “Promote Culture of Health”? Or “Promote Culture of Care”?
After all, one way leaders can test a guiding principle is to ask themselves: as people in my organization face their work challenges, will this help them know how to do it right, or better?
I don’t think #CultureofHealth helps me do my work better. Instead, it leaves me wondering how on earth I’m going to get help doing my work.
This is not to say, mind you, that I don’t have great respect and appreciation for the work and ideas of the Robert Wood Johnson Foundation. If you’re someone like me, who went to medical school planning to work on improving primary care, you can’t not love RWJF. (Nor can you avoid hoping that they’ll someday find you worthy of funding.)
Furthermore, as someone with a MPH degree, an interest in systems, a background in quality improvement, a focus on person-centered care, and unqualified admiration for Alex Drane’s work highlighting the Unmentionables that affect people’s lives, I absolutely believe in what RWJF is championing.
That is to say: I believe that we as a society must address the social determinants of health, help people feel well, and work within but especially outside of doctors’ offices, to prevent chronic health problems before they develop.
But I worry that #CultureofHealth isn’t quite right, as the guiding principle for certain aspects of health care.
So I’d like to respectfully propose we look for some complements to #CultureofHealth. It’s a great concept, but we likely need more if we are going to find a way to offer all our citizens – including the aged and the chronically ill – the care they need and deserve.
(Are you a data junkie? For data on the scope of multimorbidity and associated utilization in the healthcare system, see the figures in the Medicare Chronic Conditions Chartbook. For data on how many older adults have difficulty walking, doing errands, etc, see Figure 2-14 of the Census Bureau report on seniors.)
ISO a meme for the primary care of the medically complex
We need a meme that speaks to better primary care for people with chronic health problems, and that helps us – as healthcare providers – do our job better. Specifically, we need a phrase that reminds us to be better at:
- Seeing our patients for who they are, and not focusing excessively on their diseases;
- Inviting our patients to collaborate with us, and participate as fully as possible in being part of their healthcare, including in the setting of goals and priorities for medical care;
- Recognizing the many unmentionables – financial problems, caregiving burdens, relationship stressors, depression, substance use – that often underlie people’s difficulty in addressing other health issues;
- Respecting – and facilitating — the involvement of our patients’ families, peer communities, and other sources of support and influence;
- Helping our patients try behavioral interventions (such as exercise, stress reduction, social activities, diet changes, therapy, and even “activities that create a sense of purpose”) for the many complaints for which these help, instead of quickly defaulting to pills and procedures;
- Discussing advance care planning, and addressing people’s fear and anxieties about death and declines in health;
- Delivering the right care, at the right time, in order to help relieve suffering and optimize management of chronic diseases, so as to help our patients move towards whatever goal is a good fit for their preferences, values, and health situation.
For those of caring for Medicare patients, we need a meme like this because aging adults – and their families — are coming to us for help, but in most practice situations, we’re having a lot of trouble providing the right help. It’s even, I’m sorry to say, common for us to inadvertently make things worse.
#Cultureofhealth is great for the population at large, and will likely have a profound impact on the health and wellbeing of older Americans in the future.
But let’s also promote some complementary memes, to help inspire the work we’ll be doing helping those with aging, and with multiple chronic health problems. Let’s not just bash the “sick care” system; let’s inspire ourselves to take better care of those who are sick and suffering.
So. I want to end this post by asking for your ideas. What meme resonates with you, when it comes to the clinician’s – or even the innovator’s — work of helping medically complex patients, and their caregivers? What phrases might serve as a touchstone?
By the way, #Cultureofcare was recently used to rally support for family caregivers. I do like it as a guiding principle for our work as doctors, but would love to know what others – clinicians, patients, family caregivers – think.
