Recommended
More Related Content
What's hot
What's hot (20)
Similar to Pain points of high value care for others to read
Similar to Pain points of high value care for others to read (20)
Recently uploaded
Recently uploaded (20)
Pain points of high value care for others to read
- 1. Pain Points of High Value Care David Ring MD PhD
- 7. “In the same manner that automated blood pressure measurement and automated blood cell counts freed clinicians from some tasks, artificial intelligence could bring back meaning and purpose in the practice of medicine while providing new levels of efficiency and accuracy.” Vergehse: Humanism and Artificial Intelligence, JAMA
- 9. Pain Points of High Value Care • Inadequate infrastructure and coordination • Initially unsatisfying • Barriers to an effective relationship • Unhealthy clinician habits
- 11. DASH Score 80.0 75.0 70.0 65.0 60.0 55.0 50.0 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 20 10 0 Std. Dev = 20.42 Mean = 29.5 N = 68.00
- 16. Stress • Financial, job, housing, health, family, etc. Distress • Symptoms of anxiety and depression • PTSD • Heightened illness concern) Less effective coping strategies • Low self-efficacy, catastrophic thinking, kinesiophobia, etc.
- 17. Strategies: Infrastructure • Comprehensive Care – Social worker – Psychologist – Health Coach • Coordination • Address societal roots of illness
- 21. Misdiagnosis
- 27. Strategies: Satisfaction • Behavioral design • Relationship-centered care • Incrementalism – Self-care web sites – Decision aids – Virtual care
- 29. Patient Empowerment • “…implies that [ we ] should be giving patients the authority to take care of themselves…[ as if ] this authority is solely ours to give, or that patients need us to give it to them”
- 36. Strategies: Satisfaction • Culture change / behavioral design • Relationship-centered care • Effective communication strategies • Incrementalism • Health coaches
- 39. Unhealthy clinician habits • Status quo: comfortable with tactics that get us through the day • Excessive confidence in our expertise and abilities • Convinced that what we do works by misinterpretation of experience • Insufficient awareness of bias and fallibility • Treating illness (the state of being unwell) instead of disease (pathophysiology) • Stress contagion and counter-transference • Medicalization / Capitulation / missed opportunities
- 40. The difficulty of NOT acting The difficulty of NOT being seduced by the sense that action was helpful • Illusion that a patient disaffected after treatment elsewhere validates my approach • The reward from a patient that is happy with low value tests and treatments
- 41. Strategies: Clinician Habits • Culture of safety / Learning health system • Humility and curiosity as the key source of meaning and purpose • Find the fun in working on the pain points • Do it as a team
- 42. Pain Points of High Value Care • Inadequate infrastructure and coordination • Initially unsatisfying • Barriers to an effective relationship • Unhealthy clinician habits
- 56. Pain Points of High Value Care • Inadequate infrastructure and coordination • Initially unsatisfying • Barriers to an effective relationship • Unhealthy clinician habits
- 58. High Value Care • Comprehensive • Compassionate • Human
Editor's Notes
- Value is about helping people get and say healthy using resources wisely.
- My communication coaches encourage me to be careful with negative concepts and phrases, but I think the common idea of “pain points” used in many businesses might resonate in medicine as well. The turn to value is attempting to address the pain points of treating health and healthcare as a commodity. Before we explore the pain points of value, lets look at how alterative payment models based can address common pain points in fee-for-service.
- One pain point of fee-for-service is that a substantial amount of illness is due to unhealthy habits: Unhealthy genes, unhealthy circumstances, and unhealthy habits. As we’ll explore that includes unhealthy mental habits and coping strategies. It can be costly to work in teams and coordinate care, and fee-for-service either doesn’t reward or actually penalizes comprehensive, highly coordinated care. Value allows us to focus on holistic care rather than isolated health issues. Shoulder example.
- Another pain point of fee-for-service is variation, disparity, and inequity. Some of us get too much care. Some get too little. It’s much more profitable to do the test or treatment than to discuss it. And it’s better for business. Alternative payment models encourage us optimize the amount of care.
- In fee-for-service it’s common to feel busy, behind, and rushed. And then spending a lot of time explaining or even defending our expertise to people that want us to fix everything. Value incentivizes time for what matters. Soothe not solve.
- Anyone see a problem on this Chest CT? Value encourages us to learn from data / utilize artificial intelligence A pain point of fee-for-service is that mistakes and shortcomings are often personalized. We are expected to play the role of the hero.
- It may be counterintuitive, but technology, data, artificial intelligence…have the potential to humanize medicine and increase compassion. Loss of meaning and purpose…of joy in practice…is a major pain point of medicine how it is currently practiced.
- In alternative payment models, clinicians no longer function as expensive financial clerks. NLP and AI can get the key data elements out of a useful, practical, and expedient medical record. Something easy to enter and easy to get useful information out of.
- While alternative payment models can ease some of the pain points of fee-for-service, the turn to value creates a new set of pain points.
- Let’s consider PROMs. It takes substantial infrastructure to measure and track PROMs. But we also need an infrastructure to respond to them.
- Histogram of PROMs in 68 patients. A single common hand diagnosis. Is there one with sufficient range in pathophysiology to account for this spread? Would feel confident telling a patient on the right that curing the pathophysiology will get them all the way over to the right?
- TMC arthrosis Most people adapt to disease. Resiliency is really good for you.
- How does a patient with carpal tunnel syndrome get to this state? There must be a substantial percentage of people in the world that live long healthy lives and die with advanced median neuropathy with atrophy. Incredibly resilient people. What makes them finally come in?
- Symptom intensity and magnitude of limitations correlate better with stress, distress, and less effective coping strategies than with pathophysiology. Resiliency is enhanced by less stress, less distress, and more effective coping strategies. It’s important to emphasize because clinicians--surgeons in particular, seem willfully blind to this.
- It’s helpful to separate disease from illness. …and nociception from pain.
- Measuring PROMs—a key aspect of value-based care and alternative payment models—compels us to treat people holistically or comprehensively. Yes…even orthopedic surgeons
- This creates a pain point. People usually want to be fixed. Working on resilience isn’t as appealing. There are experts in building resilience, but we don’t usually work with them. They are not readily available and they don’t understand the problems that we treat. It’s difficult to communicate and coordinate care with them. And many times the root issues are systemic and societal. The strategies for ameliorating this pain point are to work in comprehensive teams, organize our care, and address the societal roots of illness. (Examples)
- Patient Satisfaction Customer Experience. Another pain point. High value care can be initially unsatisfying. No antibiotics for you. No MRI. No cortisone shot.
- It’s natural to have misconceptions about an illness. Every symptom I have creates several misconceptions, most of them a “prepare for the worst” type of musing. We need some way to take the stigma and shame out of those misconceptions. Like these lines…If you just go with your mind’s first impressions, you’ll think the middle line is the longest.
- If we’re going to stick to things that truly improve health, both patients and clinicians are going to have to be more analytical. More scientific. We’re going to need to be ready with our Type 2 thinking as Kahneman frames it. This simple illustration summarizes his Nobel prize winning work that teaches us how to use our mind more effectively. When a clinician conveys expertise we are often correcting misconceptions. This is a pain point. These are difficult conversations.
- But if we avoid these difficult discussions…if we concede these misconceptions, we risk misdiagnosis. Misdiagnosis of a patient’s true preferences based on their values…rather than on misconceptions. One very important one: opioids rather than treatment of stress and distress. Doctors can face violence when they have the difficult discussion about limiting opioids. That’s a real pain point. Doing the right thing risks dissatisfaction.
- Low value tests and treatments: It’s easier to do the test or treatment than explain why not Difficult discussions. A potential source of dissatisfaction.
- It can be difficult to follow the evidence “My friend had a shot and it cured it” Things that seem to work but don’t Difficult conversations. More opportunities for dissatisfaction.
- The most difficult conversation... A real pain point: Getting people to move from their somatic focus to other great opportunities for getting and staying healthy. “Are you saying it’s all in my head” Dissatisfaction.
- The health benefits of resiliency… “You mean I have to live with it” It’s easier to be passive and rely on a powerful other Working on healthy habits is hard work: healthy eating, healthy activity, healthy use of substances, healthy mindset and emotions. More dissatisfaction.
- We know that comprehensive care can help people get and stay healthy. But there are so many things in the way of people saying “Great, I’d like to work on that”, that it becomes a pain point. It can really upset people.
- The next pain point is a bit obvious because I’ve given so many examples. A genuine, trusting relationship is one of the key strategies for high value care. But there are so many barriers to an effective relationship The most important is the Imbalance of power Other issues: Trust: Disadvantaged; Hierarchy; Cultural; Language; Immigrant status; Health literacy
- Some see this imbalance in the concept of “patient empowerment”
- I mentioned how trying to be comprehensive risks reducing satisfaction. One of the barriers to a good relationship is the human tendency for a false mind / body dichotomy. Brain, mind, spirit—these concepts may evolve over time. One can foresee a future where these three have less distinction.
- And it’s not just the false separation of the mental and the physical aspects of illness. Stigma against psychosocial aspects of health is a major barrier to an effective relationship The word “psychology” evokes what is “wrong” with the mind. Depression, anxiety, catastrophic thinking. These seem to relegate us to a lesser category of humans. People might feel like they are being cast aside.
- Humans are prone to passivity and reliance on a powerful other. If I carry this lucky rabbit’s foot, everything will go my way. Instead of: if I cultivate healthy eating, activity, and mindset. Encouraging an active and matter-of-fact approach to getting and staying healthy might feel adversarial.
- Doctors are comfortable with uncertainty and probability. Patients hope for certainty in a setting of inherent ambiguity. We may come off as either incompetent or arrogant. Denying certainty may feel like stealing hope. A real relationship buster.
- An individual’s experience of a given disease, doesn’t always match the facts. And we clinicians have our own biases. This discrepancy between patient explanatory model and clinician expertise can feel belittling, dismissive, arrogant. Working to hard to address this gap can feel like an argument.
- I realize Louis CK is not a great spokesperson right now, but in this bit, he really nails some of these pain points.
- One more pain point of high value care that I want to consider: It’s really difficult to change the way we do things. Our daily habits are what we use to feel comfortable. To maintain meaning and purpose. To get through the day. Evidence and standardization may rob us of our comforting habits.
- Surgeon A would find it very uncomfortable to have to try to be more like Surgeon D. I think it’s this type of thing that depletes our joy in practice. That makes us feel burned out.
- Even those of us that acknowledge that it’s worthwhile rethinking our habits find doing so a real pain point. This list of clinician habits and tendencies are all a consequence of how the human mind works. Rationalization. Pattern formation. Type 1 thinking is a type of excessive confidence that has real benefits in situations that need prompt decision-making.
- It can be so much more difficult to soothe than it is to try and solve. Patient satisfaction and dissatisfaction often have an inordinate influence on our habits. As a high-value hand surgeon, I can tell you that my colleagues get great pleasure from telling me that they saw a patient of mine that was unhappy with incrementalism and reassurance. Hearing about my pain points is another pain point. We make diagnoses and perform surgeries that science cannot support, buoyed by the appreciation of the patient. Even when that appreciation is transient.
- I’ve outlined a few of the pain points of high value care. I’m sure you can think of many others. Now let’s start have some fun with these pain points.
- What if we no longer considered health a commodity. If we restored the balance of power back to patients
- Done well, people can find their problem with reasonable probability.
- They can understand it enough to feel comfortable and healthy,
- They can find ways to manage it on their own, and know when they should get help.
- When it’s time for help, we can make that help accessible, expedient, and friendly.
- Technology allows us to get closer and closer to an in person visit.
- I’ve done quite a bit of virtual care and I find that about 80% of what I do can be done virtually. Meeting someone at their convenience, in their home, can build trust and help create strong relationships.
- When it comes time to decide between treatment options, we can direct people to tools that help them find the option that suits their values: decision aids.
- In a simple, understandable presentation people can start to “think like a doctor”.
- They can take a quiz to make sure there are no lingering misconceptions.
- And they can use sliders to explore their values.
- We can try to set things up so that for patients and clinicians both, the natural choice is the best choice.
- Computers will never entirely replace human compassion and support. The technical part of my job is fairly straightforward.
- The pain points are mostly about non-technical aspects of care.
- And this is where the science points us…
- Osler said, “the patient doesn’t care how much you know, until they know how much you care” Maybe the pain points of high value care are just a road map for the best ways to help people get and stay healthy.