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An Indecent Proposal

[This post was first published on The Health Care Blog on 4/16/13, where they titled it “An Indecent Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week.” It has generated many interesting comments. I post it here with its more modest original title. This post is about recruiting and retaining doctors to work in primary care for medically complex elders.]


A
few weeks ago, The Health Care Blog published a truly outstanding commentary by
Jeff Goldsmith, on why practice
redesign isn’t going to solve the primary care shortage. In the post,
Goldsmith explains why a proposed model of high-volume primary care practice —
having docs see even more patients per day, and grouping them in pods — is
unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer
patients. He points out that we are replacing a generation of workaholic boomer
PCPs with “Gen Y physicians with a revealed preference for 35-hour
work weeks.” (Guilty as charged.) Goldsmith ends by predicting a
“horrendous shortfall” of front-line clinicians in the next decade.
Now,
not everyone believes that a shortfall of PCPs is a serious problem. 
However,
if you believe, as I do, that the most pressing health services problems to
solve pertain to Medicare, then a shortfall of PCPs is a very serious problem
indeed.
So
serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with
a 35 hour work week.
I
can already hear all clinicians and readers older than myself harrumphing, but
bear with me and let’s see if I can make a persuasive case for this.

The crisis we face

First,
consider the situation:
The most
pressing and urgent health services research problem society must solve is how
to restructure healthcare such that we can provide compassionate, effective
healthcare to an expanding Medicare population, at a cost the nation can
sustain.
This
is a problem with very high human stakes at hand. As we know, most older adults
end up undergoing considerable health-related suffering at some point, with
family caregivers often being affected as well. Much of this is due to the
tolls of advancing chronic diseases, such as diabetes, heart disease, COPD,
arthritis, dementia. (See this handy CMS
chartbook for the latest stats on chronic disease burden in the Medicare
population.) And a fair part of the suffering is inflicted by the
healthcare system itself, which remains ironically ill-suited to provide
patient-centered care to those medically complex older adults – and their
caregivers — who use the system the most.
Needless
to say, the financial stakes are high as well, with projected Medicare
expenditures usually cited as the number one budget buster threatening the
nation’s financial stability over the next 50 years.

A necessary part of the solution

Next,
consider an essential component to compassionately and effectively meeting the
healthcare needs of the Medicare population:
Medicare
beneficiaries – and their family caregivers – must be partnered with good PCPs
who can focus on person-centered
care, and can collaborate with them as they navigate the many health
challenges of late life.
Especially
once they are suffering from multiple chronic illnesses and/or disability,
seniors – and their families — need a stable relationship with a clinician who
can fulfill the role of trusted consultant and advisor as they go through their
extended medical journey. Healthcare for older adults almost always becomes
complex and stressful for seniors and their families. Even educated and
activated patients who are willing and able to direct their own care will need
a generalist who can maintain a longitudinal health dialogue with them, and who
can help them sort through complicated medical situations as they arise.
Now,
much as been made of teams in primary care, and the importance of moving past
our historic model of PCP as the person who knows it all, and does it all. This
change is long-overdue, and I’m thrilled to see it coming. When properly
implemented, I’m quite sure that team-based care will help older adults obtain
the comprehensive primary care services they need and want.
But
even with excellent team-based care, I believe most older adults will want and
need a PCP to function as their high-level medical strategy consultant and
collaborator.

Common challenges for PCPs of older
adults

For instance, consider the kinds of issues I routinely addressed as a general internist for older adults:

  • Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion. Good luck outsourcing this to disease management.
  • Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family. Yes these specialists should get better at explaining their thinking. No, they will probably not resolve the conflicts between their recommendations and some other specialist’s recommendations.
  • Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. For a fun read on how elderly patients routinely generate a gazillion conflicting clinical practice guidelines, read this JAMA article.
  • Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family. Also, many disease management approaches must be modified in the face of conditions such as dementia, cancer, advanced COPD, etc. I’ve spent my fair share of time taking diabetics with mild dementia off sliding scale insulin regimens. (Hello endocrinologists, please stop recommending labor-intensive blood sugar management.)
  • Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful. People have questions. Answering questions takes time and attentiveness. It’s obviously much easier to rely on the historic approach of doctors and just tell people what to do, but that’s not good care.
  • Helping patients and families prioritize and identify a few key health issues to work on at any given moment. Many older patients have 15+ items on their problem list. Prioritizing is key. (Not losing track of all the issues is hard though.)
  • Helping patients and families evaluate the likely benefits and burdens of possible medical approaches. Should that lung nodule be biopsied? Should knee replacement surgery be considered now, or still deferred? So many of the decisions we face have no clear right answer.
  • Helping patients and families cope with the uncertainties of the future. For instance, it’s impossible to predict how quickly someone with dementia will decline and become unable to live at home, but these issues are of grave concern to families and they need a clinician to talk to.
  • Addressing end of life planning. I’ve found this is often trickier in the outpatient setting than on an inpatient palliative care service.
  • Weighing in on family conflicts. I’ve often watched patients and spouses squabble in the visit over what the patient is and isn’t able to do. Similarly, adult children worried about a parent will call and ask for me to intervene. (Stop her from driving! Make him take his pills!)
I
must say that I love doing the work above. It’s deeply satisfying to help
patients make sense of all that is medically happening to them, and to support
them as they cope with their health challenges. But it’s also, as you can
imagine, difficult work that is cognitively and emotionally demanding. The
pressure of 15-20 minute visits makes things harder than they should be, but
even if we went to 30-45 minute visits, the work will remain fundamentally
intense and somewhat taxing for the provider.
Can
anyone seriously argue that we won’t need PCPs to do the work above for
Medicare beneficiaries over the next 20 years? (Plus we’ll need them do manage
dementia, falls, and all the other geriatric problems too.)
Ok.
Then if we agree that the work above is essential to the wellbeing of millions
of older adults, and is a crucial component to providing overall cost-effective
healthcare to the Medicare population, we must get serious about how we can
recruit and keep clinicians as Medicare PCPs.
The benefits of a 35 hour work week
If
the work of  Medicare PCP could be
organized so that it fit into a 35 hour work week, we’d see the following
benefits:
  • More
    clinicians would be willing to do, or stay, in the job.     Let’s face
    it, we have ample evidence that work-life balance is important to the
    younger generation of physicians, especially those with young children. As
    much as this dismays the older generation of physicians, this trend seems
    to be here to stay, so perhaps we should learn to work with it. Debt relief
    – the usual hope for attracting people to primary care – is never going to
    be enough on its own.
Given
that we are asking PCPs to actively engage with patients and families, embrace
shared-decision making, adapt to technological changes, and make a whole host
of behavior
changes, making sure that clinicians in this role aren’t burnt out by long
working hours just makes sense.
Summing it up
The
impending shortage of PCPs constitutes a national emergency. In order to
provide the growing Medicare population with compassionate, effective
healthcare at a sustainable cost, seniors will need stable relationships with
PCPs who can function as their strategic medical consultants, collaborate in
helping to meet healthcare goals, and provide emotional support.
Doing
this type of PCP work can be extremely rewarding, but it’s also cognitively and
emotionally demanding.
Structuring
the job of Medicare PCPs into a 35 hour work week would probably attract more
clinicians to the job, including those with young children. It would also help PCPs maintain the cognitive and
emotional resources needed to do the job consistently well, and could reduce
burnout in this group of key clinicians.

Why We Can’t Leave It to Business to Educate Us

[This post was first published on The Health Care Blog on 4/5/13.]

Recently I came across yet another media article with suggestions as to how digital health products can gain more widespread adoption. The writer notes that “we can learn a lot from the pharma and healthcare industries,” and goes on to discuss the importance of engaging the doctor.

This article, like many I read, doesn’t acknowledge the downsides of using pharma’s tactics.

I have to assume that this is because from a business perspective, there aren’t a lot of downsides to pharma’s tactics. Pharma, along with many other healthcare industry players (hospitals, insurance companies, device manufacturers) has overall been extremely successful from a business standpoint.

So if the intent is to help digital health companies succeed as businesses, then by all means one should encourage them to copy pharma’s tactics.

But as we know, what works for business has often not worked well for serving the needs of individual patients, or to society from a health services and public health perspective.

This despite the fact that pretty much all businesses in healthcare proclaim that they are there to serve patients and society. Of course they will say this. This isn’t surprising at all.

What I have found a bit surprising, though, is the extent to which most of the media coverage of digital health is business-oriented and business-boosting. (I suppose this is because tech has always had a very close relationship with business and consumerism.)

Now, I do firmly believe that digital health innovations are absolutely essential to solving the country’s most pressing healthcare problems. I also believe that dynamic entrepreneurial energy is generally better at developing these innovations than are academic institutions or government entities.

But I worry about the extent to which business and entrepreneurs are directing the conversation on which innovations and approaches will best serve individual patients, and society. Business’ track record in this respect is really bad. Which makes sense: once a company has invested time and resources in bringing a product or service to market, they are going to try to sell it to the rest of us, whether or not it’s good for us.

In other words, although we need business innovations to help drive much-needed change in healthcare, I’m leery of letting business dominate the outreach to clinicians and society.

So, here are some related issues that I’ve been pondering lately:

  • How to encourage the media coverage of digital health to include a little more “in the interest of patients and the public” perspective?
  • How to help clinicians, academics, and health services experts learn about digital health, in a less marketing-directed way? (I’ve been informally polling my colleagues recently: most have never heard of e-patients and know very little about digital health. This means we have hardly anyone without financial ties to industry who can talk to tech journalists or others.)
  • How to foster more constructive interchanges between the digital health entrepreneurs, who have terrific new ideas, and health experts, who should be critiquing these new ideas and providing feedback on how the implications of adopting these products at scale, and how these products might be viewed in a broader health context?

For all these questions, it seems we would need to start by providing clinicians and healthcare experts with a way to keep current with digital health trends and technologies. And this way should not be unduly influenced by marketing efforts or entrepreneurial enthusiasm.

How should clinicians, academics, and non-profit experts learn about digital health?

It’s normal for the providers of these new technologies to volunteer to do the job (as pharma has historically done when it comes to new drugs), but we need viable alternatives that have fewer financial stakes in the education effort.

The problem, of course, is that our usual sources of more-objective-information-in-true-service-of-healthcare seem really unsuited to helping us understand emerging digital health technologies. For instance, by the time any high-quality peer-reviewed research is published, the technology studied is likely to be hopelessly outdated. Likewise, expert guidelines and panels take way too long to digest, process, and present their findings. So clinicians can’t keep current by relying on these time-tested methods of curating information.

Also, there is also a volume of information problem. I’ve been trying to learn about digital health for the past six months and it’s like trying to drink from a firehose.

Hence, I’ve been thinking that what I personally really need is a source of up-to-date commentary and information on digital health that is sensibly curated, and tailored to my clinical interests, i.e. the healthcare of medically complex older adults. To date, I’ve found sites that are related to caregiving, or consumer technology for seniors, or healthy aging, or evaluating assisted living. But none about technology for geriatric healthcare in particular.

So here is my latest idea: I’ve recently been wondering if something like the Journal Watch model could be adapted, to help clinicians keep up with key developments in digital health. (I subscribe to Journal Watch General Medicine.)

What I particularly like about Journal Watch is:

  • They review several key published articles every week, most of which are clinically relevant. (Occasionally there’s something about an exciting new bioscience breakthrough.)
  • They provide a nice concise summary of the research.
  • Each article summary is accompanied by a short comment written by a clinician-editor. The comment is by far the most valuable thing to read, since these editors tend to have an excellent grounding in the pragmatic aspects of clinical work, as well as a good understanding of the health-services implications of the study.

For comparison to the idea above, consider something like iHealthBeat.org. It is fantastic that the California Healthcare Foundation provides this service. And yet, I unsubscribed a while back.

Why? The snippets are too varied – nobody has selected items of special interest to clinicians and academics focused on medical care for older adults. Plus, the snippets themselves don’t feel like they’ve been selected and edited by someone who understands my needs and priorities – unsurprising since they aren’t chosen or commented on by another general internist.

Just as Journal Watch is intended to help clinicians keep up with “Medicine that Matters,” we need a Digital Health Watch service for clinicians, tailored for different specialties, to help clinicians and academics keep up with “Digital Health that Matters.”

Journal Watch, of course, isn’t free. But then again, most good sources of information aren’t.

If we had a good method for clinicians to learn about digital health, then we might see more healthcare experts constructively critiquing the efforts of the digital health entrepreneurs.

This might not be great for every company’s business, but could be very good for clinicians, individual patients and society.

Summing it up

It’s understandable that the entrepreneurial digital health community will want to engage and educate clinicians. However, as we’ve seen with pharma and other profit-oriented healthcare industries, there are significant downsides to letting business dominate and direct clinician education.

To date I’ve found that many of my colleagues in academia know little about digital health, or emerging technology innovations. This makes it difficult for medicine’s expert community to thoughtfully engage and critique the ideas of digital health entrepreneurs.

The overall healthcare needs of society would be much better served if clinicians and academics could learn about digital health via sources that have no significant financial conflict of interest. I would love to find a “Digital Health Watch” service similar to Journal Watch.

If you can recommend a high-quality, not-too-business-oriented source of information on digital health for me to follow, please comment or send me an email.

Bye Bye Blackberry

I made a big decision this past weekend: I decided to give up my Blackberry smartphone.

Why? Like a good geriatrician, I considered the benefits and the burdens of sticking with the Blackberry. And since the burdens seem to outweigh the benefits…bye-bye Blackberry.

This was a difficult decision for me, however. To begin with, becoming comfortable with a new device for one’s daily work takes time. During the transition phase, one is slower in getting work done. Plus, the frustrations of figuring out something new can suck up a lot of mental and emotional energy. (This is part of why clinicians have conniptions when EMR systems are installed or changed.)

Furthermore, just as with my new Samsung tablet, I expect the new smartphone will also require me to spend time identifying and installing suitable apps before the device becomes truly useful. For some functions, I’ll be able to use the same apps on the phone as I do on the tablet, so that provides a certain economy of learning energy.

But in other cases, I’ll have to find apps that are specific to phone functions, such as a good voicedial app. (The Blackberry has excellent voicedial, and this is a feature that I use often.) And I’ll have to figure out how to import my phone contacts — I don’t like installing my bazillion email contacts into a phone — as well as my ringtone.

In short, although I expect to be better off eventually by switching to a new Samsung phone, the transition will cost me time and energy. Plus a fair bit of money, as the new phone is not cheap.

The burden of frequent technology transitions

As best I can tell, modern life seems to demand such transitions with increasing frequency.

For instance, my first cell phone – a Sanyo phone from Sprint – lasted from 1999-2005. Six years! I only gave it up because I was leaving the country for an extended period of time. Otherwise, it was still dutifully maintaining battery charge, had adequate signal, and kept track of everyone’s phone number for me.

In other words, after six years, this cell phone could still function as if nearly new. Furthermore, the demands I was making on the phone hadn’t really changed.

Whereas today, I find myself replacing a phone that I purchased only nine months ago. Why?

  • Phone frequently malfunctioning. This phone (a Bold 9930) worked pretty well when I first got it, but now frequently hangs and freezes.
  • My expectations for smartphones have evolved. In particular, I’ve decided I need better access to a good to-do list while out and about. This means installing a task manager app, and all the good ones are on iOS or Android.
  • Blackberry no longer being supported for certain apps I use. It’s not just that cool new apps aren’t being made for the Blackberry; developers are also withdrawing support in some cases for Blackberry. 
Some will surely say that the problem in all this is the Blackberry. It’s true that this is a troubled company and I probably should’ve given more weight last summer to its visible slide towards obsolescence. (But I love being able to answer the phone by pushing a button, rather than by swiping!)
Still, I find myself a bit disturbed by how quickly things become obsolete these days. Rapid advancements in technology are undeniably a boon. However, they seem to be demanding ever more frequent upgrades in hardware and software, with attendant costs in money, time, and attention. (For instance, new laptops seem to last less and less time before becoming visibly slow as one works.)

How will seniors and caregivers feel about frequent changes to their technology?

I’ll admit that there is a part of me that is deeply conservative and doesn’t like for my technology to change in appearance. There is something comforting about having one’s workspace (or home space, for that matter) look the way it always has looked, assuming one finds that look congenial. 
Changes in function are a little tricker. Functionality and usability does seem to (mostly) improve with new devices, but in the short term, there is often some kind of learning curve.
So I find myself wondering: if a younger, tech-interested clinician such as myself finds herself frustrated by the need for frequent tech upgrades and changes, how will my patients and their caregivers feel about this?
Will they need to upgrade their smartphones every year, in order to take advantage of the latest care coordination technology? And who will help them migrate their wallpaper, contacts, and ringtone?

Summing it up

As the capabilities of technology keep expanding, I find myself having to replace my smartphone surprisingly soon. These kinds of technology transitions cost a certain amount of money, time, and energy. Since I find the changes tiresome, I wonder how they will feel to my patients and their caregivers, who probably have less tolerance for tech changes than I do. If I were a busy caregiver, I’d be wary of depending too much on a method of organization that requires me to buy a new device and learn to use it every 1-2 years.

The Tablet Transition

[This post originally appeared on The Health Care Blog on 3/29/13.]

I purchased my first tablet a few weeks ago, and have since been thinking more about tablets for seniors and caregivers. Like many, I’ve assumed that tablet-based tools will eventually make certain aspects of healthcare easier for clinicians, for older adults, and for their caregivers. But so far I’ve found the tablet harder to use than I’d expected.

Actually, technically this is my third tablet purchase. The first was an iPad last summer, which I promptly sent back after realizing that my laptop was much better suited to supporting me in my clinical work (read my full minority report here).

The second was a Nexus 7 which I purchased as a holiday gift for my 62 year old step-father, a structural engineer. (As he’s mildly uncomfortable figuring out new-fangled technology, I set up his device and helped get him started using it.)

Now, I finally have a tablet that I’ll be keeping for myself: a Samsung Galaxy Note 10.1.

The device is slowly growing on me, but it hasn’t been quite the intuitive seamless experience that I’d anticipated. Hence I have a new perspective via which to consider tablets for people who are even less digitally savvy than myself.

Now, I should disclose that my phone is a Blackberry – the only smartphone last summer at Verizon that could be answered by pushing a button rather than swiping – but I had an iPhone from 2008-2009 and an Android phone for a month in 2011. Also, as my husband remains an iPhone devotee, I’ve found myself regularly using his phone regularly to access some app not available on my phone.

So this year I came to try these Android tablets having a little prior Android experience to draw on, as well as some iOS familiarity. Here are some of the hitches I experienced:

  • Disorientation when first getting started. This happened with both the Nexus and the Samsung. Obviously both devices walk the user through some basic setup initially, but I still found myself often perplexed and in “figure-it-out” mode. I struggled with things like figuring out how to switch between apps, decluttering the main screen, copying text, and searching the device. I found myself often turning to Google on my laptop to solve the latest small quandry of the moment.
  • Annoyance with the mobile versions of websites. Tablets are supposed to make it easy to access the web, but I found it annoying to find my usual websites presented in mobile format, especially when using the larger Galaxy Note 10.1, whose screen is not that much smaller than that of my compact Thinkpad. Not only do the mobile versions of websites look different, which takes a little getting used to, but they are often less functional.
  • Too many preloaded apps. The Samsung tablet came with 51 app icons in the app section. I feel a little overwhelmed everytime I look at the app list. I’d like to have less to look at, but I’m not sure what is deletable, or how to hide things. Many apps also seem redundant, such as having both an email app and a Gmail app.
  • But I still needed to install additional apps for functions I considered basic. For my step-father to be able to read library e-books, we had to install an Overdrive app and also a Kindle app, since the library books come in both formats. In order to be able to print to my wireless Brother printer, I had to futz around with my Samsung for well over an hour. I ended up installing a cloud print app and a Brother iPrint app, both of which continue to perplex me and neither of which creates satisfactory print jobs.
  • Difficulty finding the right app for a given need. How to read an e-book in PDF format on my Samsung tablet? The Play Books app preinstalled on the device didn’t seem to do PDFs. (Actually, it seemed to only do books purchased through the Google Play store, and annoyed me by cluttering the screen with recommendations which I couldn’t seem to get rid of.) Realizing that I’d need to add yet another e-reading app to the device, I started looking online to find a good choice. Sigh. Too many choices, hard to know which to get, once an app downloaded have to figure out how it works. Argh…
  • Hard to find a decent manual. The included quick start guides are ok for a quick start, but do not provide a lot of help for those who are lacking a certain amount of tacit knowledge, or past familiarity with the OS. It took me a while digging around on Samsung’s site to find the tablet’s complete user’s manual. Which is basically like a small encyclopedia: ok to search in, but not something that is pleasant to read from start to finish.

So these are my current conclusions about transitioning to Android tablets:

  • A fair amount of tacit knowledge is presumed. Although the included quick start guides do help one get started, they still assume one understands certain basics, like what a widget is. (I’ll admit that I didn’t know what a widget was, and am still unsure of how to use them.)
  • Becoming comfortable with a helpful group of apps takes time. One has to spend time figuring out what are the darn apps already included on the device, one has to spend time identifying additional needed apps, and then one has to learn how to use the apps themselves. This is not a trivial process, especially given the choice fatigue involved in selecting apps to use.
  • It’s an effort to avoid cognitive clutter. From the multitude of preloaded apps to the unavoidable recommended books in the Play Books reader, these tablets seem to bombard the user’s brain with all kinds of tiresome extras. I suppose the manufacturer would tell me these are meant to be helpful, but I’m sure that if one did psychological research, one would find that people have better cognitive performance and feel calmer when there is less to look at.
  • A tablet is not a substitute for a laptop or desktop. In particular, I’ve found the tablets very limiting in two specific aspects. One is web browsing capability: the mobile versions of many websites drive me slightly batty. The other is text entry: even with voice input or Samsung’s Swype-like keyboard feature, entering text still feels painfully clumsy compared to typing on a keyboard. (Yes, I could get a Bluetooth keyboard, but then I might as well use my laptop, right?) 

How we might make the tablet transition easier

Here’s what I think someone like me – or even my step-father – needed in order to transition more easily to the tablet:

  • Coaching on the basics of using the operating system and the device. Ideally this tutorial is adapted to the type of new user: my step-father and I will have different needs from this kind of tutorial, because even though we are both new, we have different learning styles and comfort levels with new technology. Alternatively, if there had been a Samsung Galaxy Note 10.1 for Dummies book, I would’ve bought it as the Dummies series is usually much more readable and practical than the user’s manual. (I imagine the poor Dummies authors are having trouble keeping up with Android updates and the general pace of tech evolution however.)
  • Needs assessment and recommendations on which apps to use. The dream scenario would be to talk to a capable person about what you’d like to use the device for, and then have good apps recommended (without undue influence from the app makers). Bonus if the apps can be installed and configured for you. This is, of course, the role that many younger adults play for older adults wanting to use a tablet or new digital device. And many of us rely on a tech-savvy friend to recommend apps to us; otherwise the choices easily become overwhelming.
  • Help optimizing frequently-used apps. Even if one is using a well-designed app or program, one often doesn’t get the best use out of it without either making an effort to the learn the ins-and-outs, or getting some guidance from an expert. The ideal scenario is for someone to watch one using the app, and then make a few suggestions as to how to use it more effectively.
  • Help decluttering the tablet. It’s nice to not have too much to look at, and it makes it easier to find the apps that one actually uses. A decluttered tablet would likely be especially helpful to those who are very busy (i.e. caregivers, doctors), very stressed (caregivers, doctors), or cognitively impaired.
  • Access to someone who can answer questions as they come up. So nice to be able to talk to someone when one runs into yet another little hitch. Many of us again will rely on a more tech-savvy friend or family member. Otherwise, online forums can provide some of this functionality, but of course one needs to search them.
  • Remote control and viewing of one’s tablet. I gave my step-father his tablet when he was here in San Francisco visiting us for the holidays, but a week later my parents returned to their home in Arizona. This made it much harder for me to help him with his tablet. I found myself wishing there was a way for me to view and configure his tablet remotely, just as the Lenovo support team remotely controls my laptop when I call them for support.

Summing it up

Tablets and their associated apps can in theory be useful tools, especially for digital health purposes. However, my own recent experience transitioning to an Android tablet was harder than I expected, leaving me to wonder how we might make the process easier for boomer caregivers and for older adults. (And for other practicing clinicians, for that matter).

In particular, I found that using the tablet presumed a fair amount of tacit knowledge, and required me to do a lot of on-the-fly figuring things out. Finding the right apps for my needs and learning to use them was a bit time-consuming. Tablets are very customizable and offer a lot of choices, but all these choices can easily be overwhelming. It also takes a while to learn to use an app efficiently.

In an ideal world, I would’ve like to have access to some tailored coaching on how to use the device efficiently. I would’ve also liked to have a needs assessment and then have apps be recommended, rather than having to spend time and mental energy hashing it all out on my own. In many cases, tech-savvy people provide this kind of orientation, navigation, and troubleshooting to less tech-adept friends and family. Is there a way to provide this kind of assistance more broadly to people transitioning to tablets?

What my home renovation taught me about practicing medicine

In
2006, as I was starting my geriatrics fellowship, we started renovating our
home.
This
took almost two years from start to finish. It was a long, arduous, expensive,
and often stressful process. And this experience ended up profoundly
influencing my philosophy as a primary care physician, and my approach to
practicing medicine.
To
this day, I’ve had minimal experiences as a primary care patient – I’m in my
mid-thirties, and am lucky to have always been pretty healthy.
But
I’ve been an inexperienced homeowner trying to muddle my way through a major home
renovation, and that, I will submit, has many interesting parallels with being
a primary care patient.
For
instance, although my life and overt health wasn’t at stake, we were investing
a lot of money – and time –  into a very
complicated undertaking in which we had no previous experience. (We ended up
entirely changing the layout of our flat, including moving the entire kitchen.)
We
had to identify professionals to work with, trust in their expertise and
ability to get the job done well, yet keep an eye on how things were going and
make sure to occasionally advocate for ourselves. And when the project would be
completed, we would be the ones living indefinitely with the consequences of
our choices and our experts’ choices.
So
when I think about physician-patient relationships, I end up thinking back to
my renovation experience, remembering our experience struggling through those
two long years. I think about how we negotiated trust and control with the
professionals involved. And I especially remember who felt helpful to us, who
didn’t, and why.
Here’s
what happened with two of the key professionals we encountered, and the lessons
I learned for practicing medicine.

Two professionals, two approaches

Now,
a renovation was a something neither my spouse nor I had experience with, and
we thought hard before deciding to go for it. But it seemed to be the best of
our options: we’d decided to renovate our flat because although it was
spacious, the layout was truly terrible and the kitchen finishings were
uninspiring to say the least. (We would’ve moved, but couldn’t find anything
else that we could afford. These were the boom years in SF real estate, so it
was cheaper to refinance our existing flat and remodel than to move and double
the mortgage.)
So
we told ourselves that our hard work and investment would result in a much
better space for living and would surely improve the overall value of our home.
We checked out some books on home renovation, and then we started looking for
help getting the project done.
The
first important decision we had to make was choosing an architect. We needed
someone to help us envision how we might change and improve our flat, and then
create the plans for a contractor to follow. In other words, the architect was
going to be the linchpin of our entire experience.
But
how to choose the right architect? None of our friends had worked with any
local architects. Somehow we found a few to interview, and ending up choosing
one who I’ll call Sam (not his real name), in part because he charged an hourly
rate rather than a percentage of the entire project.
Sam,
we realized over the next few months, was a big mistake. Although he was
capable and experienced as an architect, we repeatedly clashed over details of
the emerging design, and the experience of working with him was stressful. He
pooh-poohed our request for a pantry, since that interfered with the elegant
visual balance of his proposed kitchen design, and rolled his eyes when we
asked for a hallway door to separate the bedrooms in the back from the noisier
front part of the house.
Sam,
in other words, was more interested in realizing HIS vision for our home than
he was in helping us figure out how to create a comfortable space that met OUR
needs. He also didn’t have much patience for discussing little things, like our
making sure there were lots of electrical outlets conveniently placed.
Sound
like any professionals you know?
As
things got rockier with Sam, we started to consider the unthinkable: terminating
our relationship with him, and having someone else supervise the construction
based on Sam’s plans. This was a scary proposition to us: we didn’t like working
with Sam, but how to make sure we found someone better?
After
all, we needed SOMEONE to keep guiding us through the renovation. Despite my
doing constant research in online forums and through books, we were overwhelmed
by the complexity of the project, and I was terrified that we’d make more wrong
choices and end up with a mediocre outcome after investing so much in the
project.
Then
we took a look at our contract with Sam, and realized that although we had been
paying him for his time drawing the plans, the contract stipulated that plans
are “Instruments of Service” which remain property of the architect. In other
words, if we terminated the relationship, no plans to keep working with.
It
was, of course, a contract provided by the American Institute of Architects.
And as such, all the boilerplate heavily favored the interests of the
architect, not of the homeowner.
Luckily
for us, Sam himself proposed we terminate the relationship, and agreed to give
us the right to the plans, in exchange for our paying him for his time thus
far.
As
the strictly architectural work on the project had been completed, we opted to
replace Sam with a more affordable interior designer. This time, we were lucky
enough to find a very good person to guide us through the gazillion design
choices we still needed to make: Gale Melton.
Like
Sam, Gale charged an hourly rate, had years of experience, and had a good sense
of design.
But
unlike Sam, Gale made an effort to get to know our tastes and priorities, and
then applied her skills to help steer us towards designs that WE liked. Instead
of asking us “What do you want?” and looking impatient when we couldn’t
respond, she took time helping us discover and then articulate our preferences.
And throughout the following year, she helped us effectively process and
finalize a truly staggering number of design choices.
In
short, one expert professional performed a core part of his job but left us
stressed and frustrated. Whereas the other helped us navigate a dizzying array
of decisions and was instrumental in our creating a living space that is
comfortable, appealing, and a good fit for our needs.

Primary care physician as consultant


Would
I be the doctor I am today if I hadn’t gone through this renovation experience?
I’m not sure, especially since it took place during a formative time in my
clinical geriatrics training.
In
fact, as we were struggling with Sam in the fall of 2006, I completed two
months on the palliative care service. This was probably the most valuable and
concentrated clinical learning experience I had as a trainee, and included a
lot of teaching on communication skills. And of course, teaching on discussing
goals and adapting to people’s preferences.
These
two overlapping experiences prompted me to think long and hard about how physicians
help patients, especially in primary care.
My
conclusion was that how we practice as professionals isn’t just about having
sufficient depth of knowledge and the requisite technical skills.
It’s
also about our fundamental assumptions regarding how those skills should be
applied.
From
my renovation experience, we discovered that as homeowners we really wanted to
work with experts who:
·        
Made
an effort to understand our preferences, and helped us articulate them
·        
Educated
us so we could more effectively participate, and helped us understand likely
downstream consequences of certain choices
·        
Respected
it when we prioritized things differently from the expert
·        
Appreciated
that we had much more at stake in the project than the expert did
·        
Were
understanding when we occasionally sought an extra opinion from a third party,
or otherwise tried to double-check something
·        
Were
patient with multiple questions or attention to details
·        
Could
explain how recommendations were linked to a certain understanding of our
preferences or priorities
And
of course, we discovered that we *didn’t* want to work with experts who acted
as if they knew what was best and were annoyed when we didn’t agree.
We
also realized that we wanted to be able to switch experts, and if we ever have
to go through a renovation again, we’ll be sure to negotiate terms that allow
us to easily take our business elsewhere if we discover that an expert isn’t a
good fit for us.
So
in my own work as a primary care physician, I’ve tried to think of myself as a
consultant to the patient. My job is to serve the patient, usually by helping
him or her understand the medical situation and the options, and then working
out a feasible plan to move towards the person’s health goals.
Different
patients, of course, want different things. Some ask a lot of questions, others
don’t. Some are directive – in which case part of my job is to speak up if I
think the direction they’re taking is unlikely to lead them where they said
they wanted to go — whereas others really want direction (in which case the
clinician still needs to ask where they want to go).
Am
I as successful as I’d like to be in implementing this approach? I don’t really
know. I’ve gotten some nice feedback from patients and families over the past
several years, but ideally I’d have some more objective method of getting
feedback. (Or feedforward, as it were.)
Still,
I think this approach is overall sound, and is consistent with medicine’s
ongoing transition away from its historic paternalism, and towards approaches
that are more respectful, collaborative, engaging, empowering, and individually
tailored towards patients’ needs.
Now,
can anyone recommend a favorite tool or technology that allows providers to
quickly learn whether they are properly adapting to their patients’ needs or
not?
And
what metrics will ACOs use to encourage providers to act more like excellent
consultants? Or will ACOs even care, as long as utilization is controlled?
Fodder
for future blog posts.


Summing it up

My
approach to practicing primary care has been strongly influenced by my
experience slogging through an extensive home renovation, a process which
required my husband and I to depend on professionals for guidance and to
actually implement this major project.
We
discovered that some professionals were much more stressful to work with than
others, and found that we needed to work with those who were willing and able
to use their expertise to help us meet our goals. This meant we needed
professionals who were not only technically competent, but also had the skills
to solicit our goals and preferences, and then effectively collaborate with us.
Healthcare
is making a much-needed transition towards organizing around patients’ needs
and preferences. For me, it’s been helpful to think of my primary care role as
being a medical consultant there to help patients understand their medical
situations, and then assist them in reaching certain healthcare goals. However,
I haven’t yet identified a robust way of getting feedback on my performance.