I remember looking with increasing frustration all over the basement of the hospital for his office. I had allotted some extra time to find my destination; but I was becoming more and more anxious as I feared that I was lost. I did not want to be late. I made several requests for help with directions but my anxieties only grew as each new set of directions led to more confusion and more certainty that I would be late.
My anxiety peaked when my progress was blocked by a set of big heavy double doors. I opened the doors expecting to continue toward my elusive destination down the hallway, but to my surprise I found myself standing on a platform. Descending from the platform was a set of stairs that led to what appeared to be a sea of iron lungs.
My first reaction was that the scene reminded me of the naval yard that I had seen in Portsmouth, Virginia where there were acres and acres of battleships that were “in mothballs” following their service in World War II. I had never seen an iron lung “in person” although I had seen enough pictures to know what I had discovered. I can not remember how long I stood there looking at what appeared to me to be hundreds of iron lungs that were neatly arranged in long rows. I do remember being overwhelmed by the site and the flood of memories and emotions that were spawned as I imagined each iron lung with a child in it.
I back tracked from the iron lungs and discovered that I had missed a turn. I did eventually find my way to my advisor's office. In was not till later that what I saw hit me. It has stayed with me for the the intervening 48 years. In a sudden and unexpected way the discovery brought back difficult memories of all of the fear that I had experienced as a child and a memory of all of the sadness associated with the real disease of some of my classmates. The “iron lung” was the symbol of the disease that killed some and left many in braces and facing many future years of surgeries, therapies and struggles with a disability that they would carry for life. What had confused me and terrified me as a child was the apparent random way that the disease chose its victims. Until the Salk vaccine your only defense was the good fortune to be passed over.
You can imagine my surprise this week when by chance I read an article about the invention of the iron lung in 1928 by Philip Drinker, an “industrial hygienist” who was working at the Children’s Hospital and the Harvard School of Public Health. Although the article mentions only Dr. Drinker, he had a codeveloper who was Louis Agassiz Shaw. Their apparatus was used successfully for the first time 87 years ago this past week on October 12, 1928. My “research” also revealed that about two years ago five of the old iron lungs were discovered in the basement of an old abandoned mental hospital in Lakeville, MA. I hope that you click on the links if for no other reason than to look at the terrific pictures.
Unfortunately, as we were all to learn by the eighties, there were long term consequences of polio for many of our classmates who had survived their initial attacks. Many of those who now are battling post polio syndrome had made recoveries from their initial attacks or adapted to their residual disabilities only to discover decades later that there was yet another challenge for them to face. Post polio syndrome is one last insult from this disease that seems to keep coming back like Glenn Close’s character who would not die in “Fatal Attraction”. In time post polio syndrome should also go away since according to the CDC we have been “polio free” since 1978.
I ask myself now why what I saw had such an impact on me and why has the moment stayed with me for so long? An answer might be that polio was the one disease that I had seen “defeated” up to that time in my life. Our battle against polio does seem to be a “complete victory” if you disregard post polio syndrome. The eradication of polio is the quintessential demonstration of the power of the combination of science and public effort with public and private funding (The National Foundation for Infantile Paralysis was started in 1938 by FDR, himself a victim, and later became the March of Dimes). We have done a better job with polio than with many other diseases, but the lessons learned and the hope that we have from the defeat of polio has surely carried over to our efforts against other diseases. The victory over polio has encouraged us to believe that in the future we will once again have another equally decisive victory over our current challenges. All of the organizations today that fight diseases like cancer, diabetes, heart disease and AIDS owe something to the experience and success with polio and those realities are interesting in retrospect now, but I do not think that explains why I was so moved.
I would like to say that the experience was the origin of my conviction that healthcare is a collective and not an individual activity. Certainly the story is at least a demonstration of what individuals can do when they join their efforts in pursuit of a shared goal or cause. I could write my autobiography along the lines of a continuous process of discovery that we can do more together than alone.
I am sure that the event reinforced my resolve to become a doctor. As I reflect now I see many things that the experience underlined for me but mostly I was inspired by the obvious evidence of victory over such a terrible disease. Over the years the vision of that sea of iron lungs lying like battleships in mothballs has been a sustaining memory and a reminder that as much as our patients want effective treatment of diseases when they get them what they really want is our help completely avoiding disease.
It is much better to get a “shot” or a sugar cube to stay well than the benefit of a piece of machinery to help you breathe or a surgery to compensate for a paralysis that could be avoided. However we respond to the many stresses of this moment, we have a responsibility to continue to develop our ability to prevent or avoid disease.
An Argument, Sort Of
Fortunately for me (and for you) the two articles were paired with an interview between Dr. Goroll, Dr. Mehrotra, and Stephen Morrissey who is the Managing Editor of the NEJM. The interview is available to you by clicking on the link below. It is well worth the fifteen minutes that you will invest if you decide to listen.
Whether you listen or not the interview reveals that neither author thinks that the annual physical as currently practiced by most physicians should continue. Dr. Mehrotra goes so far as to say (at 11:07 minutes into the interview) that he and Dr. Goroll are in complete agreement on several important points.
- In its current form the annual physical is not working. We need to have some kind of visit that focuses on relationship building.
- Most annual blood work is unnecessary.
- We need some kind of review visit but it does not necessarily need to be done on an annual basis.
Dr. Mehrotra goes on to say that the points where they disagree seem to him to be “more minor” and are:
- What goes into the “relationship visit”
- How often does the “relationship visit” happen
- What is the content of the visit
- It is not necessary for all adults. (He thinks it may be most appropriate for those who do not come in for other issues.)
- “Relationship building” does not represent a good enough reason to continue the current practice of an annual physical since many patients see their doctor in the course of a year for many other things during which time relationships can be built.
Dr. Goroll was not buying the arguments. In his rebuttal he emphasized the importance of trust in the therapeutic relationship and was not willing to accept the idea that it could happen on a visit for an episode of belly pain or some intercurrent illness. Dr. Goroll is focused on how the annual physical can be improved through better medical homes so that more time can be carved out for relationship building. The discussion ends with an assertion from Dr. Mehrotra that reinforces the economics,
“..primary care physician time is a valuable societal resource. We have evidence that many patients who are ill are having a difficult time getting appointments with primary care physicians.”
He goes on to say in essence that with the expansion of care under the ACA many people are not able to get the access they need. He points out that with 240,000,000 adults it is an unrealistic use of resources to perpetuate the use of the annual physical.
I have been saying for several years now that ultimately access or workforce issues, not finance, will be our greatest challenge. For every adult in our country to have a PCP and get care with the regularity and focus that we have lead patients to expect from primary care is a physical impossibility. To do so would require that panel sizes approach 10,000 patients per PCP over the next few years. Every mode of care must be balanced against the expectations of patients and has limitations induced by expectations and the standard work of those delivering the care.
This week’s NEJM has a disturbing Perspectives article entitled “Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine” by Lisa Rosenbaum. For me the article further makes the case that we have carried the current practice model about as far as it can go. The combination of our desire to expand access and reduce cost in the face of a model of practice that has not really changed in over a century or at least over the 70 years that I have been a patient, brings us to a moment of increasing chaos with patients being vulnerable. I presented the same picture three years ago when I was asked by the Massachusetts Medical Society to deliver the “Annual Oration”.
The answers may lie in team based care, ACOs and robust Medical Homes but our progress toward solution has been slow. We are actually losing ground in many ways because in many practice sites physicians are trying to continue to practice as they always have practiced, while mastering a host of external demands like the EHR, ICD 10, and the shift to new payment methodologies. In that context I must practically align with Dr. Mehrotra for the moment though my heart still lies with the concept of using an annual visit to develop relationships. Dr. Goroll is realistic. He does see a need for redesign. I know from personal experience with him that he is a champion of the PCMH as an innovation.
The question that emerges from the conversation between Drs. Goroll and Mehrotra becomes how do we innovate in such a way as to both build relationships and see all the patients who need to be seen? Everyone deserves attention to their current problems and also to the problems they could avoid. How are we going to do that within the context of the Triple Aim Plus One?
The search for the answer to a similar question in any other industry would be considered a business opportunity. Prudent people in another industry would probably turn to innovation and better engineering of systems and resource utilization. Their desire to be successful in achieving their goals would probably enable them to let go of what was impossible to maintain and encourage them to invest in processes and the deployment of expensive assets in new and more productive ways.
Can we let go of fixed ideas about methodology of what constitutes practice and imagine new ways to get to the outcomes that we desire? To use a phrase from an old song we need “new ways of walking”. Practically we need leaders, tools and a common vision of the possible. There should be many more conversations like the one brokered between Dr. Goroll and Dr. Mehrotra. The future of practice and the vision of Triple Aim Plus One desperately call for productive conversations coupled with an attitude that allows discernment of a better way to deliver care that flows from the exchange of ideas.
One Curse Continues. Is There Another New Curse?
As a boy I tried hard to master the game of baseball. My friends and I loved to play “sandlot ball” and we had a lot of fun. We had a variety of variations of the game depending on how many bodies we could round up. When there were only two of us, we would just get a trash can lid for a home base and practice pitching. Despite a lot of effort, I was horrible. Perhaps “incredibly inconsistent” would be a better description of my lack of talent. One of my first accommodations to the reality of a lack of competence was to give up my dream of being a baseball player at any level of competition after “Pony League” and try my hand at football. Even in that game where my marginal fine motor skills and lack of fast twitch muscle fibers could be balanced by extra effort and a willingness to absorb physical abuse, I eventually got to the place where I knew there was no next move.
A great description of where the Chicago Cubs find themselves now is “incredibly inconsistent” and “no next move”, at least this year. I was fooled. They disposed of the Pirates as if they were a triple A team and the Cardinals never figured out what hit them even though they had the best record in the league. How do you explain 4 and out? When we have no explanations, we turn to the metaphysical. I know it sounds crazy but I think the curse is still there from that goat that did not get to go to the game.
The fall days are getting shorter and colder and I know that the fishing season will be over soon. There is a short interruption between when you can fish from a kayak on the water and when the ice is thick enough for ice fishing. I have not caught a decent fish since the Cubs beat the Cardinals. I do not know if there is a connection but while their efforts produced no wins, my efforts produced no fish. The walking is great though and who knows, maybe I will enjoy a trifecta this week end with decent walks, better fishing, and a Patriots victory over the Jets. I hope that your team wins and that you get some great exercise for yourself. Slow twitch fibers are great for walking. Maybe you will find a scene as beautiful on your walk as the spot on my walk pictured in today’s header.
