October 11, 2022 • 27 mins
Barry digs into theories behind medical care and how practical wisdom fits in. Is low-tech, high-touch care, like the attention you would get from a parent, the best way to treat a patient?
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Speaker 1 (00:11):
Lessons from the world's top professors anytime, anyplace, world history
examined and science explained. This is one day university. Welcome.
(00:37):
You're listening to episode six of The Happiness Formula. I'm
your host, Mike Coscarelli, and ma'am, I am so happy
you're here. Over the last few episodes, we've learned some
of the principles of practical wisdom, about avoiding extremes and
knowing that there's a time and a place to be
(00:58):
brutally honest. Today we talked about finding happiness in the
medical community. Barry takes us to a place where doctors
treat their patients like their own children, using skills outside
of medical school. I gotta tell you the results of
their work are gonna amaze you. Anyway. Let's get started,
(01:28):
So let me begin by reminding you of what it
is that makes work good. A lot of this comes
from the discussion of perma that positive emotion, engagement, relationships, meaning,
and achievement that are keys to uh, to happiness, keys
(01:49):
to well being. So what makes work good is being
engaged by it. That is really losing yourself in the task,
immersing yourself, throwing yourself into the tasks that face you,
how having some control and autonomy over when the work
(02:09):
is done and how the work is done. This is
important both because people like to have control over their
lives and because having control over the work implies trust
on the part of the people who supervise you. I
don't have to tell you, I don't have to micro
(02:30):
manage you. I trust that you know what the objective
is and you'll find a way to achieve it. Meaning
being able to say at the end of the day
that you've accomplished something that has some positive effect on
the world. Relations with other people, social relations, and that
(02:50):
can be coworkers, or it can be customers and clients.
Good relations with the people you work with and the
people you work for. Our major contributors to satisfaction with
work accomplishing something actually feel like there's an achievement at
the end of the day or at the end of
the week that you can be proud of and challenge.
(03:14):
Achievements are nice, but they're not so nice when they're
kind of trivial when anyone could do it. If it
requires overcoming obstacles and learning new things, then it feels
much more significant and much more rewarding. So all of
these features of work when work is good, overlap substantially
(03:38):
with the components of perma that we talked about earlier.
And so let me give you an example of wisdom
at work. And I think this is an example that
is really a profound importance in modern industrial, affluent societies
(03:58):
like the US. It concerns in medicine the current major
problem that medicine faces in the developed world, and that
the problem that medicine faces is not curing disease, because
(04:20):
it has kind of figured out how to cure most diseases. Instead,
the problem medicine faces is in managing diseases that can't
be cured, managing hypertension, managing diabetes, managing obesity. You know,
(04:43):
you're living with this as a patient, and the question
is what can be done by the doctor and what
can be done by you to make this chronic condition
tolerable so it's not a serious threat to your longevity.
And the thing to notice about chronic conditions is that
(05:06):
there are real limits to what doctors can do because,
for the most part, managing chronic conditions requires active participation
from the patient, and often it requires active participation doing
things that patients find difficult to do, so here's an example.
(05:30):
This concerns a middle aged woman named Viba Gandhi who
was at the Special Care Center in Atlantic City. She
wouldn't be there if she were simply suffering from a
sore throat or the flu, or had broken a bone
that she needed set. Instead, the fifty seven year old
(05:52):
Viba was there because she suffered from multiple chronic conditions.
She had diabetes, she was obese, she had congestive heart failure,
she had suffered her third heart attack, and her coronary
artery disease was so advanced that it couldn't be operated.
When she arrived at the clinic in a wheelchair for
(06:14):
her first visit, she would lose her breath and suffer
severe chest pain after taking only a few steps. A
heart transplant is often the next step in such cases.
What was she doing in a place like the Special
(06:35):
Care Center, which was a primary care clinic, not a
high tech place, with two physicians to nurse practitioners, a
full time social worker, a front desk receptionist, and eight
full time health coaches. Well, this clinic, which was one
of a number of primary care centers discussed by Atul Gawande,
(07:00):
in a magazine article. This clinic focuses on a special
kind of primary care that has been emerging increasingly in
the US in recent years. The centers aim to provide
an alternative to hospital emergency rooms for patients with complex
medical conditions and few economic resources, patients who often incur
(07:26):
some of the highest costs in America's healthcare system. Emergency
rooms might be just the thing if you're hit by
a car, but they're not adequate for patients with complex
chronic problems. The forty year old with drug and alcohol addiction,
(07:46):
the four year old with advanced Alzheimer's disease and pneumonia,
the sixty year old with heart failure, obesity, gout, and
a bad memory for keeping track of his eleven medications,
and a half dozen specialists each recommending different tests and procedures.
It like arriving at a major construction project with nothing
(08:09):
but a screwdriver and a crane. In other words, emergency
rooms are not the place the right place for treating
these kind of chronic conditions anyway. V Ba Gandhi credits
this clinic for her great health improvement. She still has
(08:29):
a purse full of medications for her fragile condition. But
a year and a half after becoming a clinic patient,
she's out of her wheelchair. She can walk a quarter
of a mile at a time with her walker. I
didn't think I would live this long, she said. I
didn't want to live, but she had her husband barat
(08:51):
credit changes in diet, exercise, strict monitoring of her diabetes,
and subtle medication adjustments. In interviewing her, Gowande wanted to
know why she didn't follow such standard advice after her
first two heart attacks. What made the difference this time?
(09:12):
He wanted to know. Viva, said J Shree, naming the
health coach who had previously worked at Duncan Doughnuts, but
who speaks the same Indian language that she does. J.
Sree pushes her and she listens to her only and
(09:33):
not to me. Why do you listen to J. Sree,
Gwande asked, because she talks like my mother, Viva said.
The special care center in Atlantic City was organized by
Rushika Fernandopu, a young Harvard internist. Bernandipol carefully tracked the
(09:58):
statistics of the twelve DRED patients who use the clinic.
After twelve months in the program, he found their emergency
room visits and hospital admissions were reduced by more than
Surgical procedures were down by a quarter. The patients were
(10:19):
also much healthier. Among five patients with high blood pressure,
only two had poor blood pressure control. Patients with high
cholesterol had on average a fifty point drop in their
cholesterol levels, stunning Six of smokers with heart and lung
(10:39):
disease had quit smoking. In other words, this clinic, staffed
by very low tech primary care physicians and nurse practitioners
and health coaches, was doing what the massive medical industrial
complex of high tech American medicine was not. In setting
(11:04):
up the clinic, the doctor's got the counsel of another
doctor named Jeffrey Brenner, who had pioneer a similar clinic
in Camden, New Jersey, about an hour away from Atlantic City,
and one of Brenner's AHA moments was meeting and treating
a patient named Frank Hendricks he had asked. Brenner had
(11:29):
asked emergency room doctors and social workers in Camden to
introduce him to one of the worst of the worst patients.
Hendricks was that person. He had spent as much time
in hospitals as out of them during the last three years.
He had a history of alcohol abuse. He smoked, He
(11:51):
weighed five hundred sixty pounds. He had uncontrolled diabetes, heart failure,
and chronic asthma. Doctor Brenner visited with him daily while
Hendricks was in intensive care in the feeding to having
developed tech toxic shock from a gall bladder infection. Hendrix
(12:12):
was a mess, so Brenner says, I just basically sat
in his room like I was a third year medical student,
hanging out with him for an hour or an hour
and a half every day, trying to figure out what
makes the guide tick. He learned that Hendrix used to
be an auto detailer and a cook. He had a
(12:34):
longtime girlfriend and two children, now grown. A toxic combination
of poor health, too much alcohol, and as it emerged,
cocaine addiction had left Hendrix unreliably employed, uninsured, and living
in a welfare motel. He had no regular set of doctors,
(12:56):
and he had almost no prospects for turning his health around.
Hendrix recovered enough to be discharged from the hospital after
a few months, but his life was just another hospitalization
waiting to happen, and Brenner. Dr Brenner tried to figure
out what he could do to help. He followed Hendrix
(13:19):
closely enough to spot serious problems emerging. He double checked
that the plans and the prescriptions from specialists actually fit together.
He sorted things out by phone when they didn't. He
teamed up with a nurse practitioner who made home visits
to check blood pressure and blood sugar levels and to
(13:40):
make sure that Hendricks was taking his medications. Brenner also
went beyond what you might call the usual doctor stuff
to address some of the conditions that made Hendrick's health
issues worse. He teamed up with a social worker to
help Hendricks get disability insurance so he could afford a
(14:03):
stable place to stay in stead of the chaos of
welfare hotels, and thus to enable Hendrix to have access
to a consistent group of physicians who would know him
and his case. They got Hendrix to go back to
alcoholics anonymous. They urged him to start cooking his own
(14:23):
food and to return to church. He described himself as
a devout Christian. The aim was to fight hendricks helplessness
by finding some sources of stability and value in his life.
He had given up. Can you imagine being in a
(14:44):
hospital for that long. What that does to you, Brenner wondered. Now,
a few years after Brenner started treating Hendrix, he found
Hendrix had not had a drink for a year, had
not had cocaine for two years, at quit smoking through
(15:05):
years ago. He was living with his girlfriend in a
safer neighborhood. He was going to church. He was weathering
various family crises. He had started cooking his own meals.
Is diabetes and congestive heart failure or under much better control.
He'd lost two hundred twenty pounds, which meant, among other things,
(15:26):
that if he fell, he'd be able to pick himself
up rather than having to call for an ambulance. Brenner
said working with him didn't feel any different from working
with any patient on smoking, bad diet and not exercising,
working on any particular rut that someone has gotten into.
(15:48):
People are people, and they get into situations they don't
necessarily plan on. My philosophy about primary care is that
the only person who has changed anyone's life is their mother.
The reason is that she cares about them, and she
says the same simple thing over and over again. And
(16:11):
so what Brenner is trying to do is care for
patients in the way their mothers cared for them and
say the same few simple things over and over again.
For this, you don't need a medical school degree. For this,
You need empathy, good listening, and real concern for the
(16:36):
welfare of patience. The thing about this kind of care,
the thing about the care that mothers and fathers provide
to their children, is that it's white meat. It's what
might be called high touch care, lots of personal attention
provided by a caretaker. Parents provide high touch care without
(16:58):
even thinking about it. For doctors, it's a deliberate decision,
and one for which they have had extremely little preparation.
In addition, mothers and fathers care about everything that affects
the welfare of their children. Unlike most physicians, they don't
(17:19):
wall off physical health from other aspects of well being.
Their care is directed at the whole person, and not
just at the organic machinery inside the person. And so
what Brenner was trying to do is substitute an analog
(17:39):
of parental care, a loved one care, health coach care,
someone who understands me care for the high tech, impersonal
care that has come to dominate practice in American medicine. Now,
patients like Viba Gandhi and Frank Hendricks are particularly complex,
(18:00):
with multiple chronic illnesses that require extensive and expensive medical care.
Although they constitute only a small fraction of all the
people needing healthcare in the US, the kinds of chronic
conditions they face are quite common, and partly this is
(18:21):
a direct result of medicine's extraordinary ability to treat acute
diseases successfully, at least in the developed world. The success
treating acute disease keeps people alive longer, but longevity makes
people ripe for all of these chronic diseases, diseases that
(18:43):
must be managed rather than cured, and treatment for these
illnesses demands something beyond pill, surgery, chemotherapy, and so on.
It demands that patients become partners in their own care.
It demands often that patients make extremely difficult life changes
(19:04):
and treatment as life change has become increasingly common in
the United States, as modern medicine has become less and
less about responding to acute conditions and more and more
about managing chronic conditions arthritis, congestive heart failure, hypertension, obesity, diabetes, AIDS,
(19:25):
low back pain, osteoporosis. Patients who feel vulnerable, frightened, hopeless,
depressed and confused somehow must be encouraged to participate actively
in often extremely arduous life changes. Quit smoking, lose weight,
eat more fiber, avoid salt and fat, exercise, stop drinking.
(19:50):
A doctor could diagnose a chronic condition and know exactly
what the patient has to do to mitigate its effects.
The doctor could hand the patient a printed sheet of instructions,
and the doct there would know that only a tiny
handful of patients would follow those instructions. Indeed, the doctor
(20:13):
would know that most patients already have these instructions burned
inside their heads. What is it that patients can reasonably
be expected to do as partners and treatment? This is
not the right question. The right question is what can
this patient, this particular patient sitting in front of me,
(20:37):
be reasonably expected to do well. It's time for a
quick break. But when we come back, Barry tells us
what he sees as the future of medicine. Doctors and
(21:06):
nurses need to assess what a particular patient can manage.
How to motivate the particular patient. Is it feasible to
tell this patient that she needs to lose fifty pounds
or that she needs to walk at a brisk pace
for thirty minutes a day. Will it do any good
to tell him he needs to lower the stress level
(21:26):
of his job. Knowing how to treat patients demands balancing
what is medically sound with what a patient can and
will do, and that demands understanding the perspective and life's
circumstances of the patient. What's right for one patient may
(21:46):
be disastrous for another. In other words, to practice good medicine,
a doctor must know her patient. This is why effective
medicine must be high touch medicine. This is why effective
medicine must be wisely practiced medicine. This kind of care
(22:10):
demands medical practitioners with the capacity to do the kind
of relationship building that doctor Brenner and their staff are doing,
and this in turn will demand organizing medical clinics that
encourage practitioners to learn how to provide this kind of care,
(22:31):
and also designing medical schools to encourage young doctors to
learn how to give this kind of care from the beginning.
What kind of capacities do doctors need to give this
kind of care? Well, According to Brenner, What they need
(22:52):
is obviously good medical knowledge and skills, but they need
the capacity to build long term relationships with their patients.
They need for their patients to see them as friends
or as family members. She sounds like my mother. Remember
(23:13):
that quote from the first patient I talked about. Doctors
like this need to be caring and compassionate. They need
to be careful in how they treat and how they counsel.
They need to be honest enough so that patients can
trust what they say and use the information the doctor
(23:34):
provides to make important choices about how to manage their care.
They need to be loyal to have their patients backs.
They need to be patient. They need to have the
resilience and courage to face their fears of angry reactions
from patients, of failures with patients of obstinate superiors with
(24:00):
the power to sanction them when things go wrong. They
need to be empathetic, to listen well to how patients
see the world and understand their thoughts and their feelings.
They need to balance engagement and caring about the welfare
of patients with being objective enough and detached enough, and
(24:21):
firm enough to convince or insist either gently or firmly
that patients change the way they live, change their drinking,
they're smoking, their drugs, their overeating, and so on, things
that are extremely difficult to change. So this is what
(24:44):
it takes to be a good doctor when the doctor's
task is managing chronic conditions, and increasingly, managing chronic conditions
is the ball game in developed societies like the one
in the US, and an extraordinarily high percentage of the
(25:05):
total healthcare costs faced in the United States is spent
on a very small fraction of all the patients. So
if you can manage with high touch medicine to reduce
usage of the health care system by people with multiple
(25:28):
chronic conditions, you will dramatically reduce healthcare costs in the
United States. Not with a technical solution, but with an empathic, wise,
inter personally caring and concerned solution. So what I'm suggesting
(25:48):
is that good medicine, as good work, needs to be
wise medicine, because good medicine is managing the whole person
and not the organ systems in that person that seemed
to be failing. Our medical schools don't teach doctors how
(26:08):
to do this, the insurance companies don't pay doctors for
doing this. It's hard to find clinicians like Dr Brenner
and clinics like his clinic. But this and not high tech,
is almost certainly where the future of medicine lies as
we get better and better at treating acute problems, and
(26:32):
this is where the future of medical training ought to
lie if we're going to be producing doctors who are
good at providing this kind of care. And incidentally, if
doctors find that they are able to provide this kind
of care the structure of the institutions they work in
allows high touch medicine, they will be a lot more
(26:53):
satisfied with the work they do than the medical professionals
currently are. Thank you so much for listening to episode
six next time. How So, few workplaces are focused on
keeping their employees happy and engaged, even though it's costing
(27:13):
the money. The Happiness Formula from One Day University is
a production of I Heart Podcasts and School of Humans.
If you're enjoying the show, leave a review in your
favorite podcast app, and check out the Curiosity Audio Network
for podcasts covering history, pop culture, true crime, and more.
Lessons from the world's top professors anytime, anyplace, world history
examined and science explained. This is one day university. Welcome.
(00:37):
You're listening to episode six of The Happiness Formula. I'm
your host, Mike Coscarelli, and ma'am, I am so happy
you're here. Over the last few episodes, we've learned some
of the principles of practical wisdom, about avoiding extremes and
knowing that there's a time and a place to be
(00:58):
brutally honest. Today we talked about finding happiness in the
medical community. Barry takes us to a place where doctors
treat their patients like their own children, using skills outside
of medical school. I gotta tell you the results of
their work are gonna amaze you. Anyway. Let's get started,
(01:28):
So let me begin by reminding you of what it
is that makes work good. A lot of this comes
from the discussion of perma that positive emotion, engagement, relationships, meaning,
and achievement that are keys to uh, to happiness, keys
(01:49):
to well being. So what makes work good is being
engaged by it. That is really losing yourself in the task,
immersing yourself, throwing yourself into the tasks that face you,
how having some control and autonomy over when the work
(02:09):
is done and how the work is done. This is
important both because people like to have control over their
lives and because having control over the work implies trust
on the part of the people who supervise you. I
don't have to tell you, I don't have to micro
(02:30):
manage you. I trust that you know what the objective
is and you'll find a way to achieve it. Meaning
being able to say at the end of the day
that you've accomplished something that has some positive effect on
the world. Relations with other people, social relations, and that
(02:50):
can be coworkers, or it can be customers and clients.
Good relations with the people you work with and the
people you work for. Our major contributors to satisfaction with
work accomplishing something actually feel like there's an achievement at
the end of the day or at the end of
the week that you can be proud of and challenge.
(03:14):
Achievements are nice, but they're not so nice when they're
kind of trivial when anyone could do it. If it
requires overcoming obstacles and learning new things, then it feels
much more significant and much more rewarding. So all of
these features of work when work is good, overlap substantially
(03:38):
with the components of perma that we talked about earlier.
And so let me give you an example of wisdom
at work. And I think this is an example that
is really a profound importance in modern industrial, affluent societies
(03:58):
like the US. It concerns in medicine the current major
problem that medicine faces in the developed world, and that
the problem that medicine faces is not curing disease, because
(04:20):
it has kind of figured out how to cure most diseases. Instead,
the problem medicine faces is in managing diseases that can't
be cured, managing hypertension, managing diabetes, managing obesity. You know,
(04:43):
you're living with this as a patient, and the question
is what can be done by the doctor and what
can be done by you to make this chronic condition
tolerable so it's not a serious threat to your longevity.
And the thing to notice about chronic conditions is that
(05:06):
there are real limits to what doctors can do because,
for the most part, managing chronic conditions requires active participation
from the patient, and often it requires active participation doing
things that patients find difficult to do, so here's an example.
(05:30):
This concerns a middle aged woman named Viba Gandhi who
was at the Special Care Center in Atlantic City. She
wouldn't be there if she were simply suffering from a
sore throat or the flu, or had broken a bone
that she needed set. Instead, the fifty seven year old
(05:52):
Viba was there because she suffered from multiple chronic conditions.
She had diabetes, she was obese, she had congestive heart failure,
she had suffered her third heart attack, and her coronary
artery disease was so advanced that it couldn't be operated.
When she arrived at the clinic in a wheelchair for
(06:14):
her first visit, she would lose her breath and suffer
severe chest pain after taking only a few steps. A
heart transplant is often the next step in such cases.
What was she doing in a place like the Special
(06:35):
Care Center, which was a primary care clinic, not a
high tech place, with two physicians to nurse practitioners, a
full time social worker, a front desk receptionist, and eight
full time health coaches. Well, this clinic, which was one
of a number of primary care centers discussed by Atul Gawande,
(07:00):
in a magazine article. This clinic focuses on a special
kind of primary care that has been emerging increasingly in
the US in recent years. The centers aim to provide
an alternative to hospital emergency rooms for patients with complex
medical conditions and few economic resources, patients who often incur
(07:26):
some of the highest costs in America's healthcare system. Emergency
rooms might be just the thing if you're hit by
a car, but they're not adequate for patients with complex
chronic problems. The forty year old with drug and alcohol addiction,
(07:46):
the four year old with advanced Alzheimer's disease and pneumonia,
the sixty year old with heart failure, obesity, gout, and
a bad memory for keeping track of his eleven medications,
and a half dozen specialists each recommending different tests and procedures.
It like arriving at a major construction project with nothing
(08:09):
but a screwdriver and a crane. In other words, emergency
rooms are not the place the right place for treating
these kind of chronic conditions anyway. V Ba Gandhi credits
this clinic for her great health improvement. She still has
(08:29):
a purse full of medications for her fragile condition. But
a year and a half after becoming a clinic patient,
she's out of her wheelchair. She can walk a quarter
of a mile at a time with her walker. I
didn't think I would live this long, she said. I
didn't want to live, but she had her husband barat
(08:51):
credit changes in diet, exercise, strict monitoring of her diabetes,
and subtle medication adjustments. In interviewing her, Gowande wanted to
know why she didn't follow such standard advice after her
first two heart attacks. What made the difference this time?
(09:12):
He wanted to know. Viva, said J Shree, naming the
health coach who had previously worked at Duncan Doughnuts, but
who speaks the same Indian language that she does. J.
Sree pushes her and she listens to her only and
(09:33):
not to me. Why do you listen to J. Sree,
Gwande asked, because she talks like my mother, Viva said.
The special care center in Atlantic City was organized by
Rushika Fernandopu, a young Harvard internist. Bernandipol carefully tracked the
(09:58):
statistics of the twelve DRED patients who use the clinic.
After twelve months in the program, he found their emergency
room visits and hospital admissions were reduced by more than
Surgical procedures were down by a quarter. The patients were
(10:19):
also much healthier. Among five patients with high blood pressure,
only two had poor blood pressure control. Patients with high
cholesterol had on average a fifty point drop in their
cholesterol levels, stunning Six of smokers with heart and lung
(10:39):
disease had quit smoking. In other words, this clinic, staffed
by very low tech primary care physicians and nurse practitioners
and health coaches, was doing what the massive medical industrial
complex of high tech American medicine was not. In setting
(11:04):
up the clinic, the doctor's got the counsel of another
doctor named Jeffrey Brenner, who had pioneer a similar clinic
in Camden, New Jersey, about an hour away from Atlantic City,
and one of Brenner's AHA moments was meeting and treating
a patient named Frank Hendricks he had asked. Brenner had
(11:29):
asked emergency room doctors and social workers in Camden to
introduce him to one of the worst of the worst patients.
Hendricks was that person. He had spent as much time
in hospitals as out of them during the last three years.
He had a history of alcohol abuse. He smoked, He
(11:51):
weighed five hundred sixty pounds. He had uncontrolled diabetes, heart failure,
and chronic asthma. Doctor Brenner visited with him daily while
Hendricks was in intensive care in the feeding to having
developed tech toxic shock from a gall bladder infection. Hendrix
(12:12):
was a mess, so Brenner says, I just basically sat
in his room like I was a third year medical student,
hanging out with him for an hour or an hour
and a half every day, trying to figure out what
makes the guide tick. He learned that Hendrix used to
be an auto detailer and a cook. He had a
(12:34):
longtime girlfriend and two children, now grown. A toxic combination
of poor health, too much alcohol, and as it emerged,
cocaine addiction had left Hendrix unreliably employed, uninsured, and living
in a welfare motel. He had no regular set of doctors,
(12:56):
and he had almost no prospects for turning his health around.
Hendrix recovered enough to be discharged from the hospital after
a few months, but his life was just another hospitalization
waiting to happen, and Brenner. Dr Brenner tried to figure
out what he could do to help. He followed Hendrix
(13:19):
closely enough to spot serious problems emerging. He double checked
that the plans and the prescriptions from specialists actually fit together.
He sorted things out by phone when they didn't. He
teamed up with a nurse practitioner who made home visits
to check blood pressure and blood sugar levels and to
(13:40):
make sure that Hendricks was taking his medications. Brenner also
went beyond what you might call the usual doctor stuff
to address some of the conditions that made Hendrick's health
issues worse. He teamed up with a social worker to
help Hendricks get disability insurance so he could afford a
(14:03):
stable place to stay in stead of the chaos of
welfare hotels, and thus to enable Hendrix to have access
to a consistent group of physicians who would know him
and his case. They got Hendrix to go back to
alcoholics anonymous. They urged him to start cooking his own
(14:23):
food and to return to church. He described himself as
a devout Christian. The aim was to fight hendricks helplessness
by finding some sources of stability and value in his life.
He had given up. Can you imagine being in a
(14:44):
hospital for that long. What that does to you, Brenner wondered. Now,
a few years after Brenner started treating Hendrix, he found
Hendrix had not had a drink for a year, had
not had cocaine for two years, at quit smoking through
(15:05):
years ago. He was living with his girlfriend in a
safer neighborhood. He was going to church. He was weathering
various family crises. He had started cooking his own meals.
Is diabetes and congestive heart failure or under much better control.
He'd lost two hundred twenty pounds, which meant, among other things,
(15:26):
that if he fell, he'd be able to pick himself
up rather than having to call for an ambulance. Brenner
said working with him didn't feel any different from working
with any patient on smoking, bad diet and not exercising,
working on any particular rut that someone has gotten into.
(15:48):
People are people, and they get into situations they don't
necessarily plan on. My philosophy about primary care is that
the only person who has changed anyone's life is their mother.
The reason is that she cares about them, and she
says the same simple thing over and over again. And
(16:11):
so what Brenner is trying to do is care for
patients in the way their mothers cared for them and
say the same few simple things over and over again.
For this, you don't need a medical school degree. For this,
You need empathy, good listening, and real concern for the
(16:36):
welfare of patience. The thing about this kind of care,
the thing about the care that mothers and fathers provide
to their children, is that it's white meat. It's what
might be called high touch care, lots of personal attention
provided by a caretaker. Parents provide high touch care without
(16:58):
even thinking about it. For doctors, it's a deliberate decision,
and one for which they have had extremely little preparation.
In addition, mothers and fathers care about everything that affects
the welfare of their children. Unlike most physicians, they don't
(17:19):
wall off physical health from other aspects of well being.
Their care is directed at the whole person, and not
just at the organic machinery inside the person. And so
what Brenner was trying to do is substitute an analog
(17:39):
of parental care, a loved one care, health coach care,
someone who understands me care for the high tech, impersonal
care that has come to dominate practice in American medicine. Now,
patients like Viba Gandhi and Frank Hendricks are particularly complex,
(18:00):
with multiple chronic illnesses that require extensive and expensive medical care.
Although they constitute only a small fraction of all the
people needing healthcare in the US, the kinds of chronic
conditions they face are quite common, and partly this is
(18:21):
a direct result of medicine's extraordinary ability to treat acute
diseases successfully, at least in the developed world. The success
treating acute disease keeps people alive longer, but longevity makes
people ripe for all of these chronic diseases, diseases that
(18:43):
must be managed rather than cured, and treatment for these
illnesses demands something beyond pill, surgery, chemotherapy, and so on.
It demands that patients become partners in their own care.
It demands often that patients make extremely difficult life changes
(19:04):
and treatment as life change has become increasingly common in
the United States, as modern medicine has become less and
less about responding to acute conditions and more and more
about managing chronic conditions arthritis, congestive heart failure, hypertension, obesity, diabetes, AIDS,
(19:25):
low back pain, osteoporosis. Patients who feel vulnerable, frightened, hopeless,
depressed and confused somehow must be encouraged to participate actively
in often extremely arduous life changes. Quit smoking, lose weight,
eat more fiber, avoid salt and fat, exercise, stop drinking.
(19:50):
A doctor could diagnose a chronic condition and know exactly
what the patient has to do to mitigate its effects.
The doctor could hand the patient a printed sheet of instructions,
and the doct there would know that only a tiny
handful of patients would follow those instructions. Indeed, the doctor
(20:13):
would know that most patients already have these instructions burned
inside their heads. What is it that patients can reasonably
be expected to do as partners and treatment? This is
not the right question. The right question is what can
this patient, this particular patient sitting in front of me,
(20:37):
be reasonably expected to do well. It's time for a
quick break. But when we come back, Barry tells us
what he sees as the future of medicine. Doctors and
(21:06):
nurses need to assess what a particular patient can manage.
How to motivate the particular patient. Is it feasible to
tell this patient that she needs to lose fifty pounds
or that she needs to walk at a brisk pace
for thirty minutes a day. Will it do any good
to tell him he needs to lower the stress level
(21:26):
of his job. Knowing how to treat patients demands balancing
what is medically sound with what a patient can and
will do, and that demands understanding the perspective and life's
circumstances of the patient. What's right for one patient may
(21:46):
be disastrous for another. In other words, to practice good medicine,
a doctor must know her patient. This is why effective
medicine must be high touch medicine. This is why effective
medicine must be wisely practiced medicine. This kind of care
(22:10):
demands medical practitioners with the capacity to do the kind
of relationship building that doctor Brenner and their staff are doing,
and this in turn will demand organizing medical clinics that
encourage practitioners to learn how to provide this kind of care,
(22:31):
and also designing medical schools to encourage young doctors to
learn how to give this kind of care from the beginning.
What kind of capacities do doctors need to give this
kind of care? Well, According to Brenner, What they need
(22:52):
is obviously good medical knowledge and skills, but they need
the capacity to build long term relationships with their patients.
They need for their patients to see them as friends
or as family members. She sounds like my mother. Remember
(23:13):
that quote from the first patient I talked about. Doctors
like this need to be caring and compassionate. They need
to be careful in how they treat and how they counsel.
They need to be honest enough so that patients can
trust what they say and use the information the doctor
(23:34):
provides to make important choices about how to manage their care.
They need to be loyal to have their patients backs.
They need to be patient. They need to have the
resilience and courage to face their fears of angry reactions
from patients, of failures with patients of obstinate superiors with
(24:00):
the power to sanction them when things go wrong. They
need to be empathetic, to listen well to how patients
see the world and understand their thoughts and their feelings.
They need to balance engagement and caring about the welfare
of patients with being objective enough and detached enough, and
(24:21):
firm enough to convince or insist either gently or firmly
that patients change the way they live, change their drinking,
they're smoking, their drugs, their overeating, and so on, things
that are extremely difficult to change. So this is what
(24:44):
it takes to be a good doctor when the doctor's
task is managing chronic conditions, and increasingly, managing chronic conditions
is the ball game in developed societies like the one
in the US, and an extraordinarily high percentage of the
(25:05):
total healthcare costs faced in the United States is spent
on a very small fraction of all the patients. So
if you can manage with high touch medicine to reduce
usage of the health care system by people with multiple
(25:28):
chronic conditions, you will dramatically reduce healthcare costs in the
United States. Not with a technical solution, but with an empathic, wise,
inter personally caring and concerned solution. So what I'm suggesting
(25:48):
is that good medicine, as good work, needs to be
wise medicine, because good medicine is managing the whole person
and not the organ systems in that person that seemed
to be failing. Our medical schools don't teach doctors how
(26:08):
to do this, the insurance companies don't pay doctors for
doing this. It's hard to find clinicians like Dr Brenner
and clinics like his clinic. But this and not high tech,
is almost certainly where the future of medicine lies as
we get better and better at treating acute problems, and
(26:32):
this is where the future of medical training ought to
lie if we're going to be producing doctors who are
good at providing this kind of care. And incidentally, if
doctors find that they are able to provide this kind
of care the structure of the institutions they work in
allows high touch medicine, they will be a lot more
(26:53):
satisfied with the work they do than the medical professionals
currently are. Thank you so much for listening to episode
six next time. How So, few workplaces are focused on
keeping their employees happy and engaged, even though it's costing
(27:13):
the money. The Happiness Formula from One Day University is
a production of I Heart Podcasts and School of Humans.
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