In my most recent time at ICSI, I’ve learned more about patient engagement, activation, empowerment, and how we need to move our patients from passive consumers of care to partners in maintaining their health.  We glibly use the term “patient-centered care” from the IOM report, Crossing the Quality Chasm, as a beacon for our work.

But while our profession espouses those values, I fear we have much to do, and a long way to go to truly engage our patients/citizens as partners in their health management.  As we strive to understand the need to “activate” our patients, and provide the resources and support for them to become active participants in their health, there are many challenges to address in our traditionally paternalistic delivery of health care.

My lovely wife, Robin, recently had eight of her close friends from high school spend a weekend at our home, catching up on their journeys in life.  I was humbled and impressed by the closeness and mutual affection of these women, continuing a relationship that originated in their childhood.

One of her classmates, a bright, motivated, active professional, had been diagnosed with breast cancer over 20 years ago, and “cured” with a return to an active, successful life style–eating correctly, exercising regularly, doing all the right things.  Until…. she began to experience right hip pain several months ago, which became excruciating.  Initially told she had arthritis, and inexplicably being prescribed Oxycodone and Fentanyl to manage the pain, within 24 hours she was hospitalized, diagnosed with recurrent metastatic breast cancer, with a pathologic fracture of the head of the right femur into the hip joint, and staring hip replacement, rehabilitation, radiation therapy, and chemotherapy in the face.   It reminds us how quickly our lives can change, and why we should cherish each and every day we have.

While at our house, this activated, enlightened, engaged patient outlined her story of recent care at a large, well-known and reputable health care institution. I was embarrassed and appalled.  As she dealt with her rehab, her need for intensive therapies, and the unexpected complications that arose, I felt a sense of sadness, which evolved into frustration, and then to anger.  For she had been forced, in a time of utmost personal distress, to assume responsibilities which should have been, and could have been, supported by us in the health care system.

As she explained her need to personally call insurance companies, pursue her surgeon and oncologist to obtain answers to questions, all at the same time she is trying to put her personal and professional life together again, I felt extreme embarrassment that we as a profession and a “system” have placed such a burden totally on her shoulders.  Because she works alongside the health care system, she had knowledge and resources, as well as an incredible personal resolve, to tackle the repeated obstacles and barriers to getting the care she deserved.   And I wondered–if this was what someone who had the knowledge and resolve to fight the inefficiencies thrown at her by our disorganized, fragmented care system, in one of our most respected health care organizations, what does that say about what we’re forcing others to do?  And I silently wept, and felt an overwhelming sense of sadness, but increasing resolve.

As I share with her and several of her friends my passion and interest in the area of engagement, I received an acknowledgement, and encouragement, to continue my focus, my challenges to the present cacophony of supposed support.  We are at a critical time in our country in addressing health care.  The need to truly engage our patients, to provide them with the resources to be partners in care, to understand the world in which they live (which is not in our clinics and hospitals) is critical.

It is often said that inspiration comes from unusual places.  It is likely that my already strong resolve was enhanced by a random conversation in our living room, and the personal embarrassment I felt for the journey we were forcing on this patient–no, not this patient, my wife’s friend and colleague–and it became personal.  Thank you for reigniting my passion…and inflaming my indignation.  There’s work to do….

The advances in the treatment of cardiovascular disease in the past 50 years are remarkable. Automated external defibrillators (AEDs), the devices you see in airports and other public places, change out-of-hospital cardiac arrest from a death sentence to an event with some chance of survival. Coronary angioplasty (ballooning the blockages in the arteries that feed the heart) during a heart attack reduces deaths by about 50%. Implantable devices that pace and shock the heart when a life-threatening heart beat occurs reduce the risk of death by more than 40%.¹

These statistics and the current emphasis on individualized medicine might suggest that, if a community can afford high tech health care, it doesn’t need to invest in parks, bike ways, tobacco-free homes and workplaces, access to affordable fruits and vegetables, and the other health promoting environments.² But the data demonstrate that the path to health for every community and every individual, rich and poor alike, requires health-promoting physical and social environments.

Let’s do the math for the high-tech treatments of heart disease and two of the fundamental determinants of health–physical activity and healthy food. The best estimate of what will happen to an individual is what will happen to others in their community. It is simple to calculate the community impact of any intervention if just four parameters are known: (1) the extent to which an intervention will reduce “event rates,” (2) the event rate for eligible individuals who participate in the intervention, (3) the number of eligible individuals who have not yet taken part in the intervention, and (4) the number of people in the community who are eligible for the intervention.

For example, using deaths that might be prevented or postponed (DPP) as “the event,” we can calculate the impact of meeting the physical activity guideline for healthy Americans.

For a population of 30-84 year-old Americans:

• The mortality rate of physically active individuals is 30% lower than the mortality rate for inactive individuals;
• The death rate is 1,007/100,000;
• 70% of those able to be active are currently not active;
• In a population of 100,000, the number of apparently healthy individuals is 90,024.

Therefore, the DPP that could be achieved if the entire healthy population were to become physically active is 0.30 x 0.01007 x 0.7 x 90,024, or 190.

In 2009, we published the expected DPPs for nutrition, physical activity, tobacco and several heart disease treatments.¹ We calculated the impact of improving performance from current levels to achieving 100% goal attainment.  We found that the number of deaths that might be prevented or postponed in a community of 100,000 adults ages 30-84 would be:

• 1.9 if AEDs were placed in all public places and people who worked there were trained in their use;
• 15.1 if all individuals with heart attacks received angioplasty;
• 63 if all individuals who met the criteria received an implantable defibrillator or biventricular pacemaker;
• 158 if everyone met the dietary goal of five servings of fruits and vegetables every day;
• 159 if no one smoked and no one were exposed to second-hand smoke, and
• 334 if everyone met the physical activity goal of 150 minutes per week.

We found that improving care for acute heart disease events could at most prevent or postpone 8% of deaths in the U.S. population ages 30-84. Taking full advantage of the benefits of good nutrition, adequate physical activity, and elimination of tobacco would prevent or postpone 49% of all deaths.  If our calculations considered the impact of all community determinants of health on all ages, the predicted impact would be considerably larger.

It is indisputable that access to medical care saves lives, but the math demonstrates that, regardless of the resources that might be committed to health care, there is only one path to significantly healthier communities.  That path is mobilizing action to improve the physical and social environments in which we live.

Thomas Kottke, MD, MSPH is Medical Director for Population Health with HealthPartners in Bloomington, MN.

Nico Pronk, Ph.D. is Vice President and Health Science Officer with HealthPartners in Bloomington, MN

References

1. Kottke TE, Faith DA, Jordan CO, Pronk NP, Thomas RJ, Capewell S. The comparative effectiveness of heart disease prevention and treatment strategies. Am J Prev Med. Jan 2009;36(1):82-88 e85.

2. Mobilizing Action Toward Community Health (MATCH): Population Health Metrics, Solid Partnerships, and Real Incentives 2012; http://uwphi.pophealth.wisc.edu/. Accessed December 20, 2012.

It’s complicated. Changes are flying at us at an accelerating rate, clashing and clanging against what we thought was certain. Legislative measures that may or may not prevail, changes in how performance is evaluated, changes in reimbursement, changes in the roles of all involved – seemingly the only thing for certain is change. What will be the opposite and equal reaction?

Let’s take stock of the current situation. The anticipated shortfall of primary care physicians if the Affordable Care Act (ACA) remains in force is estimated to balloon to more than 60,000 by 2025. Whether or not the ACA remains in force, the active patient population will continue to grow as baby boomers age. This burgeoning patient population is adding to the strain caused by increasing multimorbidities and chronic conditions. Medicine, like aviation, is going to face greater demands and an increasing need for more experts.

This change in the environment will require changes in behavior. Parts 1 and 2 of this series explored how medicine learned from aviation’s work on changing behavior. It started with the checklist, moved into Cockpit Resource Management, and then evolved into Crew Resource Management. Aviation had made huge strides in recognizing that, in order to optimize resources in the work environment, it was essential for all crew members to be actively involved. With Crew Resource Management’s team approach widely implemented and on its way to being mastered, the fiercely competitive aviation industry (manufacturers and airlines) scanned the environment for a concept to leverage to lower training costs, improve safety and deal with the shrinking pool of already trained pilots from the military. And so they were seduced by the siren song of automation.

While automation has improved costs and safety, commercial aviation is now in the midst of the painful process of recognizing and adjusting to the unintended pitfalls of automation reliance. In a fascinating recording of an American Airlines pilot training session, Children of the Magenta, over-reliance on automation is the key concept. The trainer repeatedly demonstrates how pilots rely on automation even when they can clearly use manual controls. He cautions that “in 68% of accidents, automation dependency plays a critical part in leading crews… to allow their aircraft to get much closer to the [edge of the envelope] than they should have.” In other words, their reliance on automation has caused them to neglect their critical thinking.

Understanding why automation can lead to failure is important. One interesting study of automation’s surprises contained in Handbook of Human Factors & Ergonomics points out that the implicit promise of automation technology is that it increases precision and efficiencies while reducing the potential for human error. However, that promise can come up short because the human-machine interaction cannot replicate the “basic competencies” of human-human interaction. Humans have difficulty remaining actively engaged while monitoring – the place automation puts us. We disengage and lose situational awareness.

Moreover, automated systems tend to “switch off” in complex situations where they may be needed most. The person monitoring may not be sufficiently oriented to the situation to handle it effectively. Even worse, key bits of information can be masked by well meaning efforts to simplify matters for the human monitoring the process. One widely studied accident occurred in part because key information needed by the crew was masked.

Similarly, in medicine, technological advances have created opportunities to reduce the likelihood of error through systems design and processes. As the number and variety of ways to automate performance increases, so does the reliance on those mechanisms. Physician shortages and finite resources coupled with increasing demand create a pressure to do more with less. Automation may again seem to be the silver bullet. Aviation has learned that automation can help but it comes with its own pitfalls. Health care can avoid these potential pitfalls by learning from aviation’s experience.

So how are we in health care being seduced by automation? It’s easy to see how enticing high-tech diagnostic imaging and robotic surgery can be. Here are some more discrete real-life examples:

• Physicians increasingly request decision support to help them with clinical implementation. An example of this is clinical indicators by condition.
• Electronic medical records (EMR) are being designed so that the physician cannot digress from the protocol embedded in the EMR without documenting the reason.
• Workstations are being set up and work flows designed so that the clinician has a limited set of options for actions and activities.

Again, automation in itself is not inherently bad. It is when it is used so widely and extensively that critical thinking falls to the wayside that issues start to arise. Here are some examples of automation’s unintended consequences:

• Electronic dosing schedules that do not include maximum dosages can result in overdosing if there is an over-reliance on the system.
• When processes are developed to reduce error and ensure the clinician “does the right thing,” opportunities for critical thinking are being designed out of the process.
• Over-focus on the processes may cause the obvious to be missed. One patient shared her recent experience with a hospital room not being tended as it should. It escaped the floor nurse’s attention although the nurse’s station was in close proximity to the room because there was no “check room cleanliness” prompt on her computer screen.

Aviation and health care’s shared draw to automation and the potential for negative unintended consequences has not escaped notice of those straddling both industries. One such individual, a clinician from Sydney, pointed this out on a pilot’s forum. He commented, “You know, this is a broader cultural issue. We are seeing the exact same paradox in medicine. Everything is being reduced to autopilot with clinical pathways and guidelines. This approach inevitably de-emphasizes critical thinking, and clinical decision making skills are being lost as a result.”

The impact of a loss of focus on critical decision-making skills now may have a large impact in the future. The commenter continues by pointing out that medicine is like an apprentice system where students and junior physicians model their future practices after what they observe. They are likely to practice what they learn.

He points out that while the benefits of automation may be immediate, the true cost may not be realized for years, and cautions, “This is like aviation. All the airlines have followed this path for years – in part due to regulatory requirements, but also due to significant economic benefits. But people are now starting to question the consequences.”

The risk for error in both health care and aviation increases when the automation is highly complex or inconsistent. Additionally, the visual and tactile cues that can increase situational awareness are often casualties of automation design process. For example, debates have continued to wage for years about the value of a flight yoke versus a side stick because of the related loss of visual and tactile clues provided by the yoke to all the crew in the cockpit. Similarly, there are scores of unintended consequences from each design choice and philosophy. Perhaps one salient lesson is to design these cues in to the process instead of out.

Health care has benefited from incorporating aviation’s quality and safety improvement tactics into our industry, but often only after the long passage of time, many lost lives and wasted resources. We have an opportunity to head off the worst of automation’s unintended consequences by designing automation in a way that fosters critical thinking skills.

But within the last several months, I’ve had an “opportunity” to reassess, and reconsider this long- standing approach. First, while it may seem trivial, I had a birthday in June. OK, I know that’s an annual event, but this was a special birthday. For while I was attempting to ignore the reality of time, I had to contact CMS earlier this summer and become enrolled in Part A of Medicare. Ouch, that hurt. It raised in a very real way that I’m closer to the December of my career and life, than the summer of my expectations. I suspect it will be hard for many to understand, but for me it was an awakening of a realization that I had already been given a fair share of time on this earth, and there are no guarantees I’ll be given an infinite amount of time to accomplish all those things I’ve put on hold.

Secondly, after 26+ years in clinical practice, and an incredible 10 ½ years at the Institute for Clinical Systems Improvement, I’m transitioning to a “part time” status in my unique role as Chief Knowledge Officer. There are many reasons for doing this—wanting more time to spend with family, playing more golf, freeing my time up for other “opportunities” which might arise, feeling a bit like I’ve lost some of the influence and involvement in my tasks. But starting in a few weeks, I’ll have anywhere from 8-10 more days a month to fill with whatever it is I’d like. For someone who’s never worked less than 50 hours a week for over 47 years, it would seem that would be a desirable goal, but it is with a bit of trepidation I move into a role which seems less impactful, less intense, less intriguing.

But then, there’s the bucket list discussion. As an avid golfer (OK, avid doesn’t equate with “good” but more accurately describes my enthusiasm) for decades, I’ve watched hundreds of golf tournaments on television. For over 40 years, I’ve fantasized what it would be like to play Pebble Beach on the Monterrey peninsula in California. I’m quite certain that the golfers reading this will totally understand and commiserate with that “bucket list” item. And it’s happened!! Over Labor Day weekend, three other similar bucket list devotees and myself took the pilgrimage to Monterrey and had the opportunity to play Pebble Beach.

While expecting to have my sense of anticipation exceed my actual experience, I can now say that the experience was almost religious, and was exhilarating in a way I cannot describe. As I walked in the shadow of all the greats who’ve played the game, enjoying the sun, the breeze, the view, I was struck by the intensity of the emotion in the moment. I was also struck by the need to relook at my bucket list, and my Medicare status, and my transition, and reboot my life.

This may seem maudlin, it may be self-evident, I may be overdramatizing. So be it, but while I move toward the next phase of my life with some anxiety, and some sense of trepidation, I choose to look at it as another door opening, and opportunities and experiences which I’ve only thought about before becoming reality. In fact, I’ve been a Green Bay Packer fan for over 5 decades, yet for many reasons (listed above) I’d never been to Lambeau field. In the spirit of my new status, I made another pilgrimage, traveling to Green Bay to watch a classic match between the Packers and the Chicago Bears. Imagine, after decades of “wait” I’ve accomplished two bucket list items in two weeks. It can’t get any better than this….or can it?

It’s almost here, I’m going through all those transitions feelings I’ve told others to expect, the grieving of the loss, the feeling of being disconnected, the excitement and accompanying apprehension about change…..Hey’ I’m not retiring, it’s just a chance to reexamine life, relationships, opportunities, and exploration. About that book I should write, or that skydiving challenge…just saying.

Part 1 of this blog detailed how integrating knowledge and experience from aviation into medicine was straightforward in the case of checklists. This installment explores why now is the time to move beyond checklists to a more comprehensive approach – Care Resource Mobilization. 

Care Resource Mobilization (CRM) is the optimal mobilization of available resources to engage clinicians and patients for better health, better care, and lower health care costs. There are existing resources that we can use, right now, to help that happen. Many of these resources may be unconventional, and many are available at no added cost to the health care system and are currently underutilized.

Discovering and leveraging these underutilized resources is the key to CRM. Overlooked resources can include communities, peers, families, friends. It often requires expanding the focus from just the patient to the circle of influence within which this individual dwells. Folks may be waiting in the wings ready and willing to help. They offer a resource base for everything from moral support to help with rehabilitative exercise.

Harnessing these additional resources is the reasonable and responsible thing to do. This may require changes in both clinician and patient behavior as we increasingly recognize there are areas of expertise on both sides of the exam table. Moving from the familiar paternalistic model may feel uncomfortable to all involved. Yet the complexity of medicine and the prevalence of co-morbidities has created a situation too big for clinicians to handle alone. Following the trail already blazed by aviation, we can leverage CRM in medicine to mobilize all our available resources.

The first installment of this blog explained how checklists have been readily adopted in both aviation and medicine. Adopting CRM will require broader changes in behaviors to develop a highly functioning team. This is made even more complex in medicine because we are dealing with two sets of CRM: intra-care team and care team + patient.

Whether in aviation or medicine, the focus of CRM is less on technical knowledge and skills than “cognitive and interpersonal skills needed to manage resources within an organized system. In this context, cognitive skills are defined as the mental processes used for gaining and maintaining situational awareness, for solving problems and for making decisions. Interpersonal skills are regarded as communications and a range of behavioral activities associated with teamwork.”

As mentioned, integrating CRM into medicine is going to be more challenging than it was in aviation. On the one hand, intra-care teams, like flight crews, have the advantage of common work space, training, jargon and knowledge base.

On the other hand, care team + patient does not have a common lexicon nor a common experience to build upon. They will need to “train” each other to achieve common expectations of their roles in this partnership. As is often the case, the hardest part will be getting started.

Permission and a Path

The ultimate goal of CRM in medicine, like aviation, is to have fully functional partners bringing their expertise to the situation. The realization of that goal in medicine is the Self-Mobilized Patient. A Self-Mobilized Patient feels confident they can be an active partner in making decisions about their health, carrying out those choices, and taking responsibility for their decisions.

Today, however, even if patients and physicians want to begin to work toward this goal, they may be reluctant or uncertain how to honestly and safely share their perspectives and information.

I’ve seen this in action myself. One of my work groups for a palliative care initiative included a cancer survivor and oncologist who had not previously met.  When asked about their experience with palliative care discussions, the patient piped up with, “I could never ask my doctor about palliative care. I don’t want to disappoint him.”  To which the oncologist remarked, “I could never talk to my patient about palliative care. They’d think I gave up.” Both of them needed permission and a path to honestly exchange information that they knew best.

Thus, the first and foremost means to access the resources available through patient self-mobilization is communication. The challenges associated with improving communication can seem immense, but so are the benefits. Aviation’s move from checklists to cockpit resource management to crew resource management was in response to the recognized need to improve flight crew communication. Changes in behavior were required by all crew members, regardless of their place in the hierarchy. This necessitated more than an intuitive leap and training was created to address the needed changes in behavior and culture. Fortunately, medicine’s Collaborative Conversation™ can play the same role.

There are many established approaches available to facilitate the other cultural and behavioral changes required for clinicians and patients. However, to maximize their effectiveness, the clinician must understand the patient’s level of engagement.

One tool that can be used to do this is the Patient Activation Measure (PAM) developed by Dr. Judith Hibbard. This tool helps clinicians understand where the patient feels they are on the continuum between needing to be passive to wanting to be an active participant in their health care. Modifying the interaction to the patient’s specific needs and abilities helps jumpstart the patient on their journey towards self-mobilization.

Once the initial level is understood, there are three broad categories of approach that make effective care resource mobilization: Patient Mobilization, Provider Mobilization, and Co-Creation. These approaches can work by themselves or in combination and vary in effectiveness depending on the patient’s level of engagement and activation.

Patient Mobilization methods include Motivational Interviewing, Shared Decision-Making and the Collaborative Conversation™ (for more details, follow the link to Collaborative Conversation™).

Provider Mobilization techniques include Practice Coaching, which helps practices improve in a variety of areas such as patient access, care coordination, team building and patient centeredness. These are areas of focus because improvement in these areas is proven to improve patient experience and outcomes. Another approach is Adaptive Leadership training, which can help clinicians recognize and take advantage of the opportunities embedded within changes in culture that occur as patients are increasingly self-mobilized.

Co-Creation melds the activation of patients into creating enhanced patient involvement. Peer coaching for chronic disease patients is one example.

At the core, all of these components need explicit permission from the experts to be part of the process. Remember there are two sets of experts involved here – clinicians and patients.

Whether it’s Crew Resource Management in aviation or Care Resource Mobilization in medicine, using all available resources on the team is a path to better outcomes. As medicine adopts this approach, it gets closer to its destination of better patient experience and population health at an affordable cost. Expediency is needed for the sake of our nation’s health and financial well-being.

But remember, CRM in aviation was introduced 30 years ago. What is aviation dealing with today and how can its failures and lessons help us face tomorrow (or should I say later today) in medicine? Part 3 will explore the next great challenge.

Read about the next great challenge in Part 3 – It’s Not Automatically OK.

 1 of 3

Aviation is a high stakes game that depends on meticulous execution to ensure the safety of its customers. So is medicine. But unlike medicine, the high visibility, transparency and personal risk to the providers intensifies the motivation to learn from every mistake.

As a result, a worldwide network of investigators from manufacturers, airlines, aviators and governments has evolved to provide the best technical and human factors analysis of incidents and accidents.  In the U.S., the National Transportation Safety Board (NTSB) is tasked with leading the investigations and creating reports of what happened and providing guidance on what to do to prevent reoccurrence.

Over the past century these public investigations into accidents have led to massive improvements in aviation, from both technical and human factor perspectives.  And, just as importantly, they have highlighted procedures and processes that are applicable to all high stake, highly technical endeavors, including medicine.

One of the most well known of these aviation investigations and recommendations arose from the 1935 roll and crash of a mammoth military aircraft.  As highlighted by Atul Gawande, this incident was the genesis of what evolved into the pilot’s checklist.  More than 70 years later, he outlined how aviation checklists could be utilized effectively in health care.

Aviation checklists proliferated from the 1930s on, evolving as aircraft complexity grew at an exponential rate. By the late 1970s aviation checklists were ubiquitous. Hierarchal cockpits were equally ubiquitous. Members of the flight crew rarely questioned the captain’s authority.

Then, in 1978, an NTSB investigation of an accident on a United Airlines flight to Portland, Oregon revealed risks that flowed from this cockpit ethos which checklists could not mitigate.

On that flight, United 173 experienced trouble with its landing gear and continued to circle while troubleshooting the issue. While the plane’s fuel level continued to rapidly approach a catastrophically low level, the flight crew failed to raise the critical nature of the fuel supply to the captain. The plane crashed. Ten perished.

Accident report AAR79-07 issued by the NTSB states “the probable cause of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crew-member’s advisories regarding fuel state. This resulted in fuel exhaustion to all engines. His inattention resulted from preoccupation with a landing gear malfunction and preparations for a possible landing emergency. Contributing to the accident was the failure of two other crew members either to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain.” The report goes on to say that this incident “exemplifies a reoccurring problem – a breakdown in cockpit management and teamwork…To combat this problem, responsibilities must be divided among members of the flight crew.” Further, they believe that, “in training of all airline cockpit and cabin crew members assertiveness training should be part of the standard curricula including the need for individual initiative and effective expression of concern.”

In response, United Airlines led the industry by instituting the first training program based on Cockpit Resource Management (CRM).

The roots of this training go back to a NASA workshop held in 1979 titled Resource Management on the Flightdeck, according to The Evolution of Crew Resource Management Training in Commercial Aviation. Research presented at the conference listed the human error components contributing to accidents as “failures of interpersonal communication, decision-making, and leadership.” Then the CRM process was suggested as a method to reduce “pilot error” by training flight crew to use human resources better.

This revolutionary approach was refined over the years to focus on the group dynamics of teams. The name was changed from Cockpit to Crew Resource Management. A team orientation was emphasized and course modules included situational awareness, decision-making strategies, and breaking the chain of errors that contribute to accidents. Now in existence for 30 years, CRM has become an essential part of conducting safe commercial aviation operations.

Two Experts in the Cockpit

CRM was developed to address cultural issues in aviation as The Evolution of Crew Resource Management Training in Commercial Aviation points out. This complex and highly technical environment has its own language, processes and norms. Its hierarchal environment has traditionally hampered communication between flight crew members and creates a communication void that is hard to bridge, regardless of the flight crew’s native culture. If the flight crew is from a collective society with a high power distance culture, subordinates were reluctant to question decisions and actions of their superiors. At the other end of the spectrum, captains from an individualistic native culture feel they are expected to know all of the answers and thus are less receptive to input from the rest of the flight crew. Either way, the result is the same — a high likelihood that insufficient communication would prevent the best possible outcome.

Watch what happens when we apply this concept to medicine.

Medicine is a complex and highly technical environment with its own language, processes and norms. This hierarchal environment and its nomenclature has traditionally hampered communication between the clinician and the patient. The patient may feel s/he is subordinate and is reluctant to question decisions and actions of the clinician. At the other end of the spectrum, the clinician may feel expected to know all of the answers and be less receptive to input from others.  Either way, the result is the same. There can be insufficient communication to provide the best possible outcome.

Two Experts on the Plane

Now picture the cockpit with a flight crew morphing into an exam room with a patient and clinician. The NIH King’s Fund Making Shared Decision-Making a Reality report points out that there are two experts in the room.  The clinician has the medical expertise to understand the causality, prognosis and treatment options. The patient’s expertise lies in their experience with the condition, risk tolerance, values, and preferences. Each expert has a role to play. Each has a responsibility to play that role. We need to help the patient take on this responsibility by taking them out of seat 24C and placing them in the cockpit.

Many Experts on the Team

Aviation was deliberate in its move from the term “cockpit” to “crew.”  With that change in terminology came the recognition that valuable contributions could be made by all of the flight team. Medicine can fast track this evolution by embracing the valuable role of the patient as partner while simultaneously recognizing the potential for valuable contributions from a much larger team. This larger care team could include all care team members, the patient’s loved ones, clergy, peers, and communities to name a few. Each one of this larger team has areas of expertise to contribute, potentially in previously unanticipated ways. These contributions could be in areas such as logistics, support or information and could come at little to no additional cost to the health care system.

Most of modern medicine underutilizes these additional experts, either intentionally or unintentionally. It will take widespread culture change on both sides of the patient-clinician equation to realize the potential of navigating through the efforts of many experts. Culture change requires behavior change. Aviation worked to achieve desired changes in behaviors and attitudes through its CRM approach 30 years ago.

If the time it took for medicine’s uptake of aviation’s checklists is any indication, it could be 2050 before we apply aviation’s 1980s CRM insights. Doesn’t the rising incidence of chronic conditions, co-morbidities, and an environment of increasing technological complexity make modern medicine too much for just the one expert to navigate alone? In fact, Gawande maintains that at any point in intensive care, “we are more apt to harm as to heal.”  And like pilots, we are vested in the outcome, from a moral and increasingly financial standpoint as reimbursement changes. Clearly, medicine needs its own CRM – Care Resource Mobilization.

Coming soon – read more about Care Resource Mobilization in Part 2 of 3. 

But there is an additional element to the draw of a good deal, that of obtaining a discount. And we as humans innately believe that with our superior intelligence, we have the ability to logically assess whether the discount is worthy of our interest. After all, that’s why we’re the superior race, isn’t it?

But as I continue to expand my interest in behavioral economics, and the intriguingly named “social neuroscience,” I’m becoming acutely aware that there are gaps in my knowledge and defects in my capabilities regarding that assessment capability. For while we harbor a personal bias that we’re able to identify a valuable discount, the reality is that our ability to assess a discount’s value is impacted by many underlying vagaries of human behavior. Not the least of those is whether an immediate discount is of superior value to one which would come due in the future.
But why is this of interest to me in my work in health care? Fundamentally, it’s caused me to appreciate that in addition to all the challenges we already have identified in addressing behavior change, we have evolving knowledge of another attribute that will frustrate our efforts—our personal immediate discount rate.

In a recent book Wait, The Art of Delay, Frank Partnoy addresses many issues important in understanding when delay (which some might label procrastination) is appropriate. Additionally, he addresses our need to understand the impact of an individual’s “discount rate” as it impacts that delay. If I’m given the following offer—would you take $100 today or $110 in a week, which would you take—if you don’t eat that cheeseburger and fries today, you may in the long run live a longer, healthier life, etc., etc. What is our immediate need for gratification, and how is it balanced against what might be a long-term benefit, but not immediately available to me?

Multiple studies have revealed that people often do poorly in balancing the benefit of these discounts. If we have a “high immediate discount rate,” we will take the immediate offer, and not think of the long-term implications. So if imbedded in my brain is a tendency to a satisfy a high immediate need, I’ll take that $100 today, because it’s not worth waiting that 7 days for a larger reward.

Let’s think about that in terms of what we’re often asking our patients to do in addressing their health. We’re often asking them to eat healthy (look past that cheeseburger), exercise regularly (even if you’re tired, and don’t feel you have the time), get adequate rest, drink less alcohol, all in the hope they will live a few years longer in the distant future. While that is laudable, if you examine it in the context of discount rates, if that person we’re asking this behavior of has a high discount rate, despite our strongest urgings and our heartfelt pleas, and perhaps even with their initial agreement, we all too often know what happens—pass me the ketchup for that cheeseburger, and another beer please. That’s what some will call “non-compliance” which appeases our sense of responsibility.

Why does this cause me to pause? Research has shown that there are several attributes associated with high immediate discount rates (driving me to that immediate gratification). Those who are under educated, poor, obese, have job uncertainties, are all prone to high immediate discount rates.

We need to understand and incorporate this into any of our work in improving the health of our citizens. For despite all of our efforts in health care at engaging patients, attempting to involve them as partners in managing their health, we will be challenged by the environment in which they live. If we fail to address the social determinants of health—poverty, education, public health, jobs, etc. I fear our efforts will be limited in success. That high immediate discount rate which impacts our behavior is a big part of our society today. What can we do to address that as we confront the many challenges we face in health care? Is our discounted offering compatible with the world they live in?

Yet if I were to have suggested in the past that we should look closely at what we might learn from this interesting aspect of human behavior, and apply it to health care, I would likely have been met with a steely stare, if not asked to leave the room, or limit myself from such ridiculous considerations. After all, this is serious business, with people’s lives at stake, and we have no time for such frivolity. We have lives to save.

But as we begin to consider the power of relationships, the impact of emotions on our decision-making, and the need to engage patients in new ways, it behooves us to consider the power of story telling. I originally had the feeling that this applied mainly to our need to create a vision that would engage in their care emotionally. That itself would have been enough for me.

Which is why a recent randomized trial reported in the Annals of Internal Medicine captured both my attention and my imagination. Thomas Houston, MD, et. al. reported on the impact of story telling as an intervention in managing hypertension in an inner city population of African Americans in Birmingham, Alabama. ( http://bit.ly/KvOF54 ). Briefly they evaluated the impact of providing DVDs with stories from other patients who are dealing with hypertension as an adjunct form of therapy in treating their condition.

Without going into details, they identified that those who were provided with the DVDs carrying the stories of others experienced a substantial and significant improvement in blood pressure as compared to those not provided with such stories.

As is often the case with new findings, which might be incompatible with our existing beliefs about how to impact care, it is likely we’ll see many concerns and objections to the study. I can see them now—there is a selection bias, the populations are not distributed equally, it is a unique population, it’s an inadequate number of patients…the list goes on.

But it provides an opportunity to continue to learn more about how we can address our patient’s needs in new and perhaps more customized ways. The value of narrative communication as a support for behavior change has been reported by others, but raises many questions regarding the underlying mechanisms. While the authors recognize the lack of direct evidence, it seems worth considering the power of homophily (hearing of perceived similarities between the characters and the patient) and it’s ability to increase the receptiveness to behavior change messages. It provides us with fodder for continuing to think about new ways of interacting with patients and families and the importance of relationships. Of course, in reality, Kate Lorig, from Stanford, has demonstrated the power of relationships in her Chronic Disease Self Management Group (CDSMP) program for over a decade. The CDSMP is a program that uses patients as leaders of workshops for others afflicted with chronic disease in learning how to live with those conditions. We must pay attention to the findings of this recent article, acknowledge the work done by Lorig and others as we move toward having patients as partners rather than merely consumers of health care.

It is always stimulating to me to see something that challenges the framework in which I was trained, and offers another perspective to consider. After all, let me tell you a story……

While still healthy enough to run 4-5 miles, climb stairs 2-3 at a time, dress and feed myself (although my wife might question the dressing component at times), and master the iPad, I’m fully aware that the future might hold for me the circumstances I often encountered on my rounds in nursing homes when I was in medical practice.

It was beyond sad to kneel next to a confused shell of what was once a vital, active person, reach out to touch their hand or shoulder, and gently ask how they were doing. Not knowing if they understood, or even acknowledged my presence, I felt it imperative for whatever dignity or sense of being still there, to get down to their level, make a personal contact, and try to reach through the fog which had caused them to become a part of the long-term care landscape. I am told I was beloved by many who worked in that environment for my caring and respectful attitude toward those whose lives I touched ever so briefly.

But it wasn’t necessarily just kindness, although I suspect that played a role. I think my approach was affected when I would contemplate that in 10, 20 or 30 years, that it might be me sitting there—apparently seeing a world which was often confusing, occasionally frightening, and with rare exceptions, foreign from that which I’d previously experienced. It was my hope that somehow, even if just for a minute, my “act of kindness” would cut through the fog, lift the mantle of confusion, and trigger a brief moment of presence—being in contact with the world in a meaningful and rewarding way.

We live with an aging population, and dare I say, I’m joining the ranks of those to be included in that category. Now consider the stereotypes that we apply, either consciously or unconsciously, when we discuss this aging phenomenon. We tend to see this aging population as more forgetful, slow, weak, timid, and often set in their ways.

Sadly, it’s not just the younger generation who hold those stereotypes, but it is prevalent in those of us joining that select group. In addition, as we know from reading about behavior, if we expect to see those things, they begin to become self-fulfilling. That magazine I forgot in the other room, that name which slipped from my memory, that inability to hit a golf ball as far as I used to—become prophetic of the decline that I should expect to see.

Now I know it’s inevitable that indeed I will decline. Given time, and the chance (by living long enough) we’ll all take that long journey into frailty. But what if we followed the tenets of Ellen Langer, as outlined in her book Counterclockwise, and practiced mindfulness. Mindfulness is defined in many ways, but to me it implies paying attention to the present, resisting the need to make generalizations based on our past, and projecting those expectations on others based on age, or any other infirmity.

Rather than giving up the golf game I love because I’ll eventually become unable to strike the ball as I once did, I find a new way to address the challenges presented by this opportunity afforded by age. Rather than giving up painting if that was my passion, due to arthritis, I consider how to use another approach to accomplish the same task. Rather than accepting that my memory is fading, in reality, it may be that I’m now choosing what is important in my life, and that many things previously important are now of no consequence.

I’m not an accomplished scientist like Ellen Langer and others, but I’m living the challenges we’ll all face. Let’s reexamine the criteria we use to evaluate the elderly—not imposing our view and experience but valuing their perspective. Let’s look beyond what we see, and consider the concept of change versus decay. Would not the world be a different place if we valued what we retain not what we’ve lost, take joy in what we’re now able to confront, not sadness at considering what once was, and not continue to look at any change in our behavior or physical and mental status as another sign of inevitable decline.

I’m not sure what has driven me to write this. Perhaps an upcoming significant birthday is causing a moment of self-reflection. The age I’m facing was one I viewed as “antique” in my younger years. Today, it seems much different, and I’m looking forward to enjoying what it offers. But while there’s a tendency to contemplate the future and fear the inevitable, I’m hoping to focus on the present, mindful of the wonderful situations today affords. Happy birthday to you, too. Isn’t it wonderful we have this opportunity to experience another part of this journey of life. Let’s be mindful, not mindless—and watch out as I run by you. I’ve got places to go…..

“I shouldn’t be doing that, it’s not productive.” “I must focus, it’s what is necessary to move forward.” Whatever the thought that interrupts that pleasant daydreaming interlude, it’s rarely a positive reflection on what I’ve been doing.

But now, as is often the story with my life, I find hope, and in some bizarre way, support for what has previously been an activity I reproached myself for enjoying. Lo, and behold, there is now research to suggest that daydreaming is a strong indicator of an “active and well-equipped brain.” Hallelujah, I’ve been vindicated. And for all these years, I’ve thought there was something fundamentally wrong with me. Thank goodness for a peer-reviewed journal article that reinforces a behavior native to my being.

In a recent study published in Psychological Science by researchers from the University of Wisconsin (my alma mater, even better), they suggest that a wandering mind correlates with a higher degree of what they call “working memory.” (http://pss.sagepub.com/content/23/4/375) This is defined as the ability of the brain to retain and recall information in the face of distractions. (Interesting in the face of my last blog on the Doorway Effect– http://bit.ly/HbPauJ).

In tests I won’t describe (likely due to a daydreaming interlude), the researchers have demonstrated that in subjects who admitted to being distracted, and are daydreaming, during a particularly boring task assigned to them, there was an enhanced ability to remember a series of letters presented to them, compared to those whose mind was less prone to the distraction of daydreaming prior to being tested.

It is hypothesized that the mental processes underlying daydreaming (well developed in my history) are quite similar to those important in the working memory. In fact, our ability to remember may be more strongly correlated to our tendency to think beyond our immediate surroundings at any given time (what a wonderful description of daydreaming) than to an IQ score.

I’m not quite sure what I’m to make of this, but it is yet another facet of human behavior worth contemplating. The authors do state that those who are prone to daydreaming still have the ability to train themselves to focus their attention on what’s in front of them, when necessary. It suggests that those episodes of daydreaming are tantamount to “exercising” an important part of our brain, especially valuable for one such as myself who carries a job title of Chief Knowledge Officer. I must get back to work now—wonder what I should do this weekend, where I should take my next vacation, why the sky is so blue today—yes, I feel that memory strengthening. Don’t you?