The Work of Healthcare: Back to the Future
The Work of Healthcare: Back to the Future
William B. Stewart, M.D.
As we engage the topic of work during 2012, it might be interesting to imagine what the work of healthcare providers might look like in the not-too-distant future. In the USA, the cost of healthcare continues to rise. The proportion of GDP devoted to healthcare expenditures has more than doubled in the past 25 years. Nonetheless millions of people remain uninsured and underserved. As this is being written, debate over President Obama’s federal healthcare plan continues and a Supreme Court decision on its constitutionality is pending creating significant uncertainty among all concerned. Compared with many other countries, our health outcomes are not proportional to the amount of money we spend annually per citizen on healthcare. Furthermore, there remains room for improvement with our approach to health and illness related to access, safety, quality and satisfaction.
Looking at an issue of the magnitude of health requires invoking both the reductionist and holistic philosophic approaches. One school, the reductionist, contends that you cannot understand the whole without knowing its parts. The other school, the holistic, teaches that you cannot know the parts without understanding the whole. As is the case with most profound truths, each statement is true and its opposite is also true. Therefore, to imagine the future of healthcare we must be both reductionist and holistic. Because of the complexity and variables involved, we must look to the microscopic and the macroscopic; the cellular and the cosmic; the high tech and the high touch; and the personal and the public.
It is not enough to consider the specific inciting agents of a disease or a focused treatment of that disruptive agent without appreciating the milieu in which the disease found a place to take hold. Wellness and illness exist on a dynamic spectrum. In their earliest stages most diseases are without obvious symptoms or detectable signs to even the most learned practitioners and most sophisticated diagnostic studies. Nor is one’s health the domain of teams of experts or the biotechnical alone. Health creation is an “inside job” and requires the active participation of the individual. We cannot simply farm out our well-being to experts or surrogates.
In fact, there is no issue that does not affect our well-being. Every issue is a health issue. Physical status, emotional states, absence of meaning and purpose, inadequate housing and education, toxic environments, poverty, violence, as well as lack of family or social support are all health risk factors – and only a partial list of what impacts the status of our health and well-being and the outcome of our illnesses. The specific signs and symptoms of wellness or disease are merely the tip of the iceberg. What underlies these “visible”, measureable markers of health/illness include our behavioral, lifestyle, physical, mental, emotional, philosophical, spiritual, social, environmental, economic, and geopolitical realities. Furthermore, they are all interconnected like the ecosystems in which we live. From gene pool to organ systems, medication to meditation, family to culture, village to nation, watershed to biosphere, planet to cosmos — the Earth can no more survive separated from the sun than the body from the heart, or the individual from the collective.
The juxtaposition of the reductionist and holistic approaches brings us to where we find ourselves today in the arena of healthcare. Running out of money; probing our ultimate uniqueness via elaboration of the human genome; mining the riches of technology with devices that can define us and connect us in an instant and gather and collate unimaginable quantities of data while doing so. At the same time, people are seeking a less invasive, less expensive, more humanistic and relational format for healthcare. This desire is seen in the growth in popularity of complementary, alternative, integrative and holistic healthcare. Compared to contemporary high tech medicine, these high touch practices tend to emphasize the power of wellness-promotion, illness-prevention and self-care rather than the treatment of end-stage disease. They emphasize health-creating choices regarding nutrition, physical activity, rest and relaxation, creativity and work, relationship and community, and reflective and contemplative practices. These practices are proactive, preventive, personal, and participatory. They require the active engagement of the individual and initiating action even in the absence of signs or symptoms of specific disease states.
As these high touch, high tech approaches are coordinated they hold the capacity to enhance prevention, diagnosis, treatment and most importantly – quality of life. They hold the possibility to better define and measure biological markers, be they genetic, biochemical, electrophysiological or another yet-to-be-developed “vital sign”, or something as simple and commonplace as weight or blood pressure. They have the potential of being predictive for the individual in a very personal way. Have population studies demonstrated the individual’s findings to be indicative of an impending disease at a very early stage? Should s/he continue on the same path or is a change needed based on the gathered personal longitudinal data? Is there a specific, focused treatment, compatible with the individual, which can be instituted to prevent the progression of the disease beyond this early state?
In Ayurvedic medicine (the classical practice of medicine in India) and traditional Chinese medicine, the “constitution” of the individual is determined and treatment tailored to the patient based primarily on thorough history-taking, physical examination, and an on-going relationship with the patient, his/her family, and their community. Because of the personalized approach of these systems of medicine, even people of similar age, gender and illness are likely to receive different treatments because of their unique needs. Contemporary Western medicine via its scientific, reductionist pathways is at the frontier of developing the tools to further refine such ancient empirical approaches through the marvels of modern science and technology. Will future versions of our ubiquitous cell phones be the devices to take and record personal biologic measurements? Will comprehensive genetic and blood analyses and advanced data collection and management replace today’s more limited laboratory testing, setting the stage for sequential monitoring over time and early targeted treatment intervention when deviations from the established norms are detected? Will outcomes then improve? Will this individualized biologic and data driven approach free up more time for the highly desired person-to-person interaction that defines “personalized” care in the holistic and interpersonal way rather than the scientific reductionist way? Will integrated teams in “patient-centered medical homes” dealing with multidimensional personal and social health determinants be the next preferred healthcare delivery model across the lifespan?
There is a revolution going on in healthcare. It is not confined to debates in Congress or to decisions of the Supreme Court. Nor is it about purely economic considerations. It is about the true meaning of health and healing and the moral, ethical and compassionate principles and values of the practice of medicine. It is about how we can best utilize the human and other resources available to us to create individual well-being, the public health, and planetary healing. The potential for improving the health of the Earth and of those travelling upon it is monumental. We are each healers with unique medicine to contribute to this worthy work.
Hood, L. and Flores, M., “A Personal View on Systems Medicine and the Emergence of Proactive P4 Medicine: predictive, preventive, personalized and participatory”, New Biotechnol, 2012, doi:10.1016/j.nbt.2012.03.004.
Morrison, Ian, “Massively Coordinated Care”, H&HN(Hospitals &Health Networks) Daily, May 1, 2012, http://www.hhnmag.com.