I am here till Wednesday at the International Conference on Communication in Healthcare, so please say hello, view my poster, and check out my book at the conference registration table, if you are also an attendee. Otherwise, there are two chances for us to connect (in person or over audio):

1. Reading tomorrow, October 1, at 7pm, at Argo Bookshop. (You can RSVP on Facebook.)

2. A radio chat on the Tommy Schnurmacher Show, CJAD 800AM and live streaming on-line, Wednesday, October 2, at 11:30am. Click Listen Live.

I'm looking forward to visiting Montreal next week, among other things, to present the work below at the International Conference on Communication in Healthcare. Please comment, dispute, falsify, disprove, and share.

In the early nineteenth century, there was little demand for the services of general hospitals in America. Almost no one who had a choice sought hospital care. Hospitals were regarded with dread, and rightly so. They were dangerous places; when sick, people were safer at home. The few who became patients went into hospitals because of special circumstances, which generally had to do with isolation of one kind or another from the networks of familial assistance. They might be seamen in a strange port, travelers, homeless paupers, or the solitary aged -- those who, traveling or destitute, were unlucky enough to fall sick without family, friends, or servants to care for them. Isolation was also related, but, in a converse fashion, to the kindred institutions of pesthouse and asylum. There, isolation (or respite) from the community was the intent rather than the occasion of removal to an institution.

--Paul Starr, The Social Transformation of American Medicine. Basic Books: 1982. p. 72. (The situation in 2013 is left as an exercise for the reader.)

Check out a post of mine on KevinMD.com, with a lively comment thread. It includes this question:

How do we make sure that the patients who are actually using the EMR reflect the entire population?

My favorite comment so far:

Techie: If we can do it, we should do it.

Doctor: If we should do it, we should do it.

Patient: Did someone do something?

A comment by a friend got me thinking. She mentioned that the constantly changing guidelines occasionally make her skeptical of medical advice.

It is true that guidelines change. By the same token, though, all knowledge changes. There are different ways to model the function of knowledge change. Are we asymptotically approaching truth? Does each generation of scientists invest in a new explanatory model, which is then discarded some time down the line in favor of another - a new paradigm, not necessarily closer to the truth? Or are scientists continually confronting new problems, with different narratives, so we're not so much finding new answers as dealing with new questions?

All these possibilities apply to medicine. Guidelines for, say, the optimal control of blood pressure don't change simply because we have a better idea of what the perfect blood pressure is. We have a different array of blood pressure treatments than we did just a few years ago; we have a different understanding of the relationship between systolic and diastolic blood pressure; we think a lot more about patient preferences than we did 10 or 20 years ago.

Where does this leave us? I hope not with widespread disillusionment that medicine, after all, does not inexorably march towards truth and health. Like any other empirical caravan, we trundle along for a while, get lost, find a new byway, and discover that we weren't lost at all, and now we are in an even better place than we thought possible. Or we discover that the folks with us are not merely passengers along for the ride, but they know how to drive as well as we can.

When you hear about changing health care, you might be worried about a loss of stability. I would say that understanding the world requires constant change, in a world of flux.

My wife went to a good yoga class the other day. (It was on Yom Kippur, actually - not the most typical yoga class.) I asked my wife what qualities make for a good yoga instructor, and this is what she came up with:

• Clarity
• Flow
• Pacing
• Explanation
• Kindness

I am biased, of course, but I think that this list summarizes the essential qualities of many different guides, including doctors, nurses, et al.

You can also interpret these terms in various ways. Clarity can be a quality of the practitioner themselves - someone who is transparent, easily read - or of their speech. Flow refers to the transition between parts of the visit, and pacing - to a perception of the patient (or yoga student) as much as to any objective rate. Explanation and kindness, of course, are less susceptible to interpretation.

According to that comparison, we should aim for someone to feel as refreshed and challenged coming out of the health care provider's office as they do when leaving the yoga studio, meditation space, or house of prayer.

Lately I 've seen a lot about "flipping the visit." Presumably that means this: the doctor has been in the driver's seat for far too long with the patient looking on bemused, confused, and bamboozled. Switch it around! Put the patient in the driver's seat. 

Except - wait. Is the patient treating the physician? Probably not. The patient is treating themselves! Lovely. So the physician...?

Right, right, we are talking shared decision making. There are two parties to the conversation. 

So flipping, perhaps, is not the right way to think about it. We need to come to the visit with the mind of an interior designer. Put the couch over there and get rid of that hideous, unnecessary wall. 

In this modified metaphor, who are the clients? Just the patient. She might want the doctor across the room, giving advice after a decision has been made; sitting at the table, sorting through the data with her; or perhaps down the hall, answering queries by email while she lounges at her leisure in her bathrobe, looking at open notes. 

Meta-preferences - how the patient wants the visit to be organized, what level of involvement she prefers for the physician, what she wants to get out of any given visit - are more important than is commonly realized. Neat switcheroos like "flipping the visit" are convenient mnemonics for patient-centering our system, but don't get at what individuals really want. Because that we won't know till we actually ask them.

I think everyone who sees patients, and treats a lot of them with a particular condition, comes to see that condition as a microcosm of all of medicine. And that’s the way with me and pain. For some reason—perhaps it’s because I tend to see these patients more frequently than others—I think I have more of them.

Pain, and I mean here chronic pain, has certain characteristics which are shared with many other chronic diseases. Such elements of illness are often overlooked, and focusing on the forms they take in pain might be useful in conceptualizing them.


Check out a post of mine at the ACP Internist Blog.

Do you agree with the following? In the face of unavoidable uncertainty, should providers and patients be unfailingly optimistic?

We are not very good at forecasting outcome. Firstly there is the range of severity within a particular disease. Then there is the variation in human response to disease, both physical and psychological. The will to fight the disease can lead to "miracles"of survival. Finally there are the errors of diagnosis, coupled with the pathetic inadequacy of our knowledge. The world is full of eighty-year-old aunties who were told that they had "weak chests" and that they would not live a normal lifespan. Modern equivalents of weak chests abound. The diagnoses are more precise, but the acuracy of prognosis is about the same. In the individual patient who conronts you [or as you yourself, as patient, confront your disease! -- ZB], in the face of all these likelihoods and possibilities, optimism seems to be the most rational approach. it is certainty the most fruitful and least harmful.

I edited the quote to make it relevant to today's patient-centered culture, certainly a salutary change from thirty years ago when Mendel wrote his book.

On a weekend trip to Baltimore's reductio ad freedonium of a used bookstore, a k a The Book Thing, a warehouse full of books that are yours for the taking, I finally got my hands on The Social Transformation of American Medicine. It's a classic for its sociologic description of how American medicine got this way: physicians managing to hold onto their control by dint of social and economic power. The book is 30 years old but its conclusions are still spot on.

As with any great work of history, the reader wonders if the clock can be turned back without sacrficing what we have gained. It used to be, shows Starr, that sickness was treated at home; laypeople acted as their own practitioners; and physicians had difficulty maintaining the social prestige that enabled them to set their own fees and wall off outsiders from their guild.

Of course, we wouldn't like to return to all of this. But we could imagine a health care system which involves a multiplicity of certified, qualified providers, and a greater inclusion of common sense which recognizes that for some common and nonserious conditions, a layperson can treat herself at home without any advanced imaging at all.

Can we get there from here?