Provider Strategies on Community Partnerships and SDOH

The buzzword of social determinants has demonstrated a shift in health care toward a greater focus on the person outside the patient. Health and provider organizations have found that a persons zip code is as much an indicator of health as their genetic code and that social barriers must be addressed to obtain the best outcomes.

Here are some conversations captured at #CCTC on how providers are addressing SDOH and demonstrating measurable ROI through creating successful partnerships, utilizing actionable data, and implementing sustainable health initiatives. For more lineup of speakers visit World Congress website.

Brian Bragg
Vice President, Behavioral Health and Community Integration
Access Community Health Network

Brian is a member of the Access Community Health Network Medical Operations Leadership Team, shepherding a variety of programs focused on men's health, maternal and child health, behavioral health, and infectious disease. His portfolio now includes the development and implementation of initiatives to address the social determinants affecting the health of the patients served by the organization.

Debbie Welle-Powell
Chief Population Health Officer
Essentia Health

In this role, she is responsible for integrating our community health strategy with population health. She works with market leaders, payer partners and community stakeholders to develop community-based population health and risk sharing models that focus on wellness and disease prevention for better health outcomes - with focus given to social determinants and our most vulnerable and needy populations.

Julianna Sellett is the Vice President of Community Health Initiatives for the Carle Health System.

She has over 28 years of health care experience, with special interest in organizational strategy, systems management, performance improvement, population health, as well as cross-sector community integration. Her current work focuses on improving the health, educational achievement, and economic prosperity of disadvantaged populations, with special focus on early childhood development. She is a Registered Nurse (RN) with a Doctoral degree in Nursing Practice (DNP), Master’s degree in Nursing (MSN), and Master’s degree in Business Administration (MBA). She is a Certified Professional in Healthcare Quality (CPHQ) and is Certified in Executive Nursing Practice (CENP).

Humanism in Medicine | Sandra O. Gold, Ed.D.

Sandra Gold, Ed.D. Co-Founder of the Arnold P. Gold Foundation an organization that strives to keep healthcare human.

Fostering Humanism in Healthcare

The vision for the Arnold P Gold foundation was an evolving one because my husband Arnold Gold, MD was in the in the fray for having humanistic healthcare because that's the kind of doctor he was. He found too often that the people around him who he was supposed to be working with and training, were too focused on the great technology and the new discoveries in medicine that happened in the 1980s.

He had an overarching goal to foster humanism in medicine, to make it clear about how important it was for there to be excellence in the science and use of that wonderful discovery and wonderful new technology. It was so important to the welfare of his patients but also to remember that that's only half of the skill set needed but the other half had to do with the human condition and the need for connection that people have and I think that that's all we had. When the board met for the first time, it was clear that this was a bigger project than we had originally thought about and then we realized working out our goals and having a plan that we needed to be cultural change agents. That's when it crystallized for us that we had a big job in front of us and that there were forces that were going to make for barriers to having humanism in medicine.

Cultural Change Agents in Medicine

Once we decided at the board level that we needed to be cultural change agents, we had to very important learning experiences that were necessary in that as well. What does that mean and how do you do it, what do you do on the ground, we had $0 that's really important to know. Why Arnold decided to have a foundation was a very interesting thought process. When he decided to have a foundation was based on the fact that he knew that people who had foundations had been very successful that Andrew Carnegie really had a lot of libraries that he had supported throughout America. That the Rockefeller’s did very well in supporting research facilities and etc.

I reminded him when he told me that and I said well why a foundation and I said do you have money under the bed that I don't know about, he was surprised and he told me about that why he chose a foundation. I advised him that those people had a lot of money. So, he then realized that it was going to be a difficult project to do and more difficult because we didn't have a lot of money, in fact we had no money. But fortunately along the way, there were wonderful philanthropists who understood the importance of this project and we managed to get funding that was significant from the Robert Wood Johnson Foundation, from Leonard Tow with his foundation, from the Health Care Foundation of New Jersey, those were some of the very early funders of the Goldman Foundation. The Russell Berry foundation, those were some of the very important philanthropists who were intuitive but also knew the need for this and the importance of this.

Overcoming the Odds in Achieving The Gold Standard

I think that people who have vision like Arnold did, are passionate and sincere and believe in the argument for the project. Arnold knew that anything less than humanistic care, no matter how skilful, was less than optimal. He fought up the hill and he assigned me the job of getting the money and organizing and administering the foundation and doing the projects and he was the spokesperson because it was very clear that he was a well-recognized child neurologist. He had the sixth license in the world.

He came into a new discipline as a fellow and had 88 papers to his credit and wrote most of the textbooks on child neurology at the time, so he was credible. When he spoke about the need for humanism in medicine to philanthropists, they recognized that this was something very important and it was in the plea for it. The willingness to work for it, the willingness to develop projects that would enhance healthcare that they recognize this as genuine and true.

There were detractors, in the academic pile of bricks. There were people who said that Arnold is smoking opium, if he thinks they could do something about the changing medical education or influencing it. But, just recently I had an experience, another one of my daughters who lives here in Boston had emergency surgery this past weekend and she called me up and she said, mom, you won't believe this story. She told me that the doctors had been wonderful and very patience and spend a lot of time with her explaining options. She told the chief resident who came to discharger what a pleasure it was and how humanistic that she and the surgeon had been and that her parents would have been so happy to see such humanism. The young doctor's eyes welled up with tears and she looked at my daughter Maggie, and she said, are you the daughter of Dr Arnold Gold?

And then she said, your parents have changed as she put it, the face of American medical education. And my daughter wanted to report that to me that her doctor knew what the movement was all about and represented it so well. And that she called up her surgeon immediately and said, we just operated on Dr Arnold Gold’s daughter. So I think, that Arnold would be very pleased to have heard that, to have a young chief resident understand and do what was necessary to inform correctly a patient that was going through emergency surgery.

Advice to Healthcare Providers

Humanism in medicine is not far from us, it's close to us. Connection between people by a health care provider who came into this profession yearning to do good and to help people, will find it easy to know what behaviors are good and project humanism, connection, relationship, trust and what aren't. I think the key advice I would say is keep that close to you that it's doable, it doesn't take a lot of time because one of the studies that we helped to fund a long, long time ago indicated that when doctors know how to communicate and take some interventions that help you communicate better, that your patients perceive you as spending more time with them.

So that in a study with people doctors who had communication training and those who had not that this study and it was with the University of Michigan and Columbia, indicated that the patient's thought that the doctors who had communications training spent more time with them, when indeed it was the other way around. So, that's number one, number two, people will tell you how to practice medicine and to some degree they have controlled when they own your practice or when you're a nurse on the floor or you're a young physician and it's going to be difficult that's the hard one, in the face of the kinds of push to see patients quickly - well you'll know them better than I what barriers are placed between you and your patient. Sometimes the electronic record if it's not used correctly or a barrier to your patient, you'll figure that out yourself if you are a nurse or a doctor or a social worker or anyone on the team. You'll be told and you'll remember that the doctors who you admire always came into the room and sat down on the same level with their patients and spoke to them.

My husband Arnold used to say if, I heard this just recently after he died by fellows and residents and medical students that he trained. He used to say if you have bad news to give a parent that you're to sit and you give you give some news that is not bad and then you give some news that is with problems and heartache and then you give something to do about it. Have a plan, I could give you ten examples that came in letters after he died, about how he did this and they told me that Dr. Gold always told us that when you give bad news to a parent and that could be for any family member that you always sit there and answer the questions until you look in the eyes of the parents and you see they have no more questions, then you can leave. You don't leave before that.

Now in today's pressure-cooker world of every nine minutes another patient you cannot provide the humanistic connections that are necessary. If the hospitals and the clinics understand that you will get better outcomes, if you allow humanism and relationship building that you will save money in the end. If you look at the data and you want to have it, we can give it to you. Where you can look it up that eventually will come regression to the mean about how time that you spend will be well spent with your patients that they will adhere to treatment plans better that's going to save money for a medical care that there will be fewer frivolous lawsuits. I could give you a whole list of good outcomes that will come only if you have humanistic practice.  

Key to Humanism in Medicine

Nursing assistants and those that provide real care, hands-on care are the key to humanism and medicine. Because all the other people are in and out, the doctors, the nurses now they're doing a lot of administrative stuff. The nursing assistants are the ones that people call for that most often answers the call, just recently one of my three daughters was in the hospital in New Jersey and was in a two bedded room and the woman in the bed next to us was a person crying for pain all night long.

I watched the nurses and the nurses aides as they talked to her, she had dementia as well and so she would be told well I gave you a shot and let's wait and see and if it doesn't work in an hour then I'm going to call the doctor. They were patient and kind and even though her daughter who was staying with my daughter and me we're kept up, I couldn't stop at the say bravo for these folks who were coming in through the night over and over again. Sometimes they change off, I think it’s because they had to keep their cool with her and they wanted to be kind. They were trying to help her.

It was a reminder of what the nurses do to battle for humanism in medicine when they're tired and they're working through the night, so I always say bravo to the nursing assistants and the nursing aides who are right there for the bed pan. This woman was calling to be moved up in the bed, she must have had hip surgery that I don't know exactly what happened but she kept on sliding down she thought and the nurses would say to her I pulled you up as far as I can. Nothing helped except she was quiet when the nurses were there so that they were giving her what she really needed, it was some comfort, some of the other human contact to say to her okay and they did it time and time again.  

Medical Ethos & Societal Responsibility

Sometimes people are overwhelmed at the prodigious aspects of the project. We understood something that Eleanor Roosevelt said. She said, the only way to begin is to begin. So we didn't have any big visions about what we wanted to accomplish. We wanted to foster what we knew was good in medicine, what my husband knew was important before research was able to support the evidence that he had imperatively.

So I think, I'd like to say to people who are in the health care professionals keep ethos in your mind, keep always understanding that you have to protect caring for people as the goal. You have to also protect, of course, excellence in the scientific skills needed. No one likes a dumb nice doctor, nurse or any other healthcare professionals. We need to protect and guard what we know is basic to the optimal medical care. I'm hoping that our future leaders, that the people who are involved in Planetree, who are the  leaders, they're parallel in their understanding of the need for patient centered care and that they will get stronger and we will get stronger and that this will go on and on until we see even more progress.

Preserving Humanism in Medicine

Sometimes I think about where we need to go and what we need to do to preserve humanism in medicine and what role the Arnold P foundation can continue to have. We are not there yet. We are far from there. We have the people already predisposition to humanism in medicine who gets it, and understand it. Then we have what we call the low hanging fruit who, they get it and they're on the bandwagon. We have about over 30,000 people in the gold humanism honors society and maybe up to 35,000 now.

So we have a lot of leadership now and we have white coat ceremonies at almost all the medical schools that set expectations for this day one, which was Arnold's goal. He said, at the end of medical school to get up and say an oath, it's useless. It's already four years too late. They're already the doctors who they're going to be. It's very important to get to know the people who are the doubters, the people who have been pushed into positions where their connections to their patients are severed, in a lot of different ways where, they're pressured to do things in a way that they wouldn't choose to do them. That they would practice medicine differently if they had time. So as Arnold always said in his black bag, he didn't have a lot of cures, but he had time and he had time to talk to his colleagues, get new ideas, get fresh, to have a lot of time with his residents and fellows to really teach.

Passion for Humanism in Medicine

People ask me why I'm still so passionate about this after 30 years of working on it. I came into this kind of sucked in by my husband who said here's your job, raise money for this. However, over the years as you get older, you see a lot of people who have serious medical problems in the family, in the neighbourhood, in the community. An understanding and reading, the research and seeing how much pain being sick causes, your life depends on it. I am still passionate about it, I still feel that it's one of the most important projects that we can have in medicine, to preserve what was good for 2,500 years that a doctor, a nurse, a team health care provider gives that patient care that's why it was called health care. The human connection and keeping health care human which is our tagline and  is high on my list.

Legacy of the Arnold P. Gold Foundation

I think the legacy of the Gold Foundation will be to keep pressuring for, advocating for the human connection in medicine and that our goal of beginning will continue and we'll a compass more of medicine than we have so far. Although I'm delighted to say that we have made inroads and as you hear other people have said that we have had a huge influence on the face of medical education. It's only important if that continues, so that's our goal for the legacy that we'll have fresh power to clinch the bargain for humanistic here.

Putting Patients First, Patrick A Charmel

“I've never really accepted the status quo and as long as I have the ability to influence change, I find that sustaining, fulfilling and self-actualizing” Patrick A. Charmel.

Patrick Charmel, is the chairman of the board at Planetree International and the president of Griffin Health Planetree’s parent company.

Patient Centered Approach

As president of Griffin Health and chairman of the board PlaneTree, I've been advocating for a patient centered approach to care for more than 30 years. As an acute care hospital, Griffin recognized many years ago that what we've done in the hospital industry is really focused on the needs of the provider, the physician and other caregivers like nurses, the technology that we use to deliver care.

The principle focus was on that and the patient was almost secondary and we recognized that was wrong and we needed to shift that focus. Planetree actually gave us a set of principles and a philosophy that helped us change our frame of reference to how we viewed care delivery.

The Journey to Improving Care

Over the last 30 years, we've been on the journey to use those principles to reinvent care from the patient's perspective. So early on we asked caregivers what they want from the patient experience, if they were a patient or a member of their family, what would they want from in hospital experience. We really focused primarily on the hospital experience and we had people articulate that and then we ask them to contrast what they described as the ideal experience to how we were then delivering care.

That was 30 years ago and there was a pretty big gap between the ideal that they described and how they viewed us delivering care at the time and frankly before we had asked that question and they had created that contrast between what they want from there for themselves in their family and the way we're delivering care now.

Shifting Dynamic Tension

They actually didn't see it. They didn't know that they weren't meeting the needs of patients because they had no frame of reference, but they were creating that gap. What that did was created what we call dynamic tension. So people saw the ideal and current reality and once they realized current reality wasn't the ideal, they wanted to move from where we were to where collectively we said we want to be.

That tension kind of drove us or propelled us toward the ideal and everybody wanted to be part of that because again, it was consistent with their personal values. It wasn't something that we impose on the organization. We said, what do you want as a caregiver? How would you want to meet the needs of your patients? And then as an institution, how can we remove all the barriers that prevent that from happening?

Some of it was policy and procedure, some of, is it conventional wisdom, some of is the rules and some of it is just the way we think. Some of it was physical barriers, the way the facility was designed because then we had a very traditional facility design. We changed all of that.

Designing for Patient Centered Care

I think in this work, when you talk about patient center, we definitely want to personalize care. We want to humanize care. But if you're running a large facility based organization, you're only going to be able to tailor care to a certain extent. It would be unrealistic or disingenuous for me to say that we can personalize everything we do we customize it down to the individual. I call it mass customization. There's this standard approach that we've adopted that is more patient centered that focuses more on the needs of patients in general.

Again, everything from the rules that we established and how we design the facility and then we do what we can to assess the individual's personal or special needs and make sure that we built in flexibility so that we can respond to that. Part of it is just educating empowering consumers so they can be actively involved in decisions affecting their care.

It's nice to say that we respond to people's needs, but how did they articulate their needs if we don't give them the information and the insight to be able to do that, and that's really been the foundation of the Plantree model. Planetree started as a library 40 years ago in downtown San Francisco. We're celebrating the 40th anniversary of

Planetree, but Planetree wasn't a care model until 10 years into its existence. It was a library in downtown San Francisco because its founder,  Angelica Thieriot had said, look, the only way that the healthcare system would be more responsive to healthcare consumers if we empower consumers and the way you do that is through access to information.

Well, there was no internet. People couldn't google it. So they went and they created a medical library that was staffed by trained medical librarians that was open to the community and created this groundswell of informed consumers. That's what motivated the healthcare delivery system to change, once we empowered consumers to be more involved, to play a more active role in their own wellbeing.

Maintaining a Standard of Excellence

It really resonated with me personally and like most caregivers, I was drawn into healthcare because I wanted to make a difference in people's lives. Frankly I want to do important and meaningful work. And when I started to see-- and I wasn't at the beginning of my career, but fairly early on in my career that the way care was being delivered, the way hospitals operated was doing a disservice not only to patients but caregivers, I felt sort of a responsibility to change it.

Then when you begin to make changes and you see the impact that's having, it motivates you to do more. As Planetree grew on, we were the first affiliate of the Planetree network, there were five models sites. Griffin was the first affiliate, we helped start the affiliate network and then it grew from there. When you create a community of like minded organizations who are trying to change the world, it's very energizing.

So learning from others who are also on the same journey, even if you lost your enthusiasm, we're all very competitive. If the community is moving and you're lagging, even though you might have started this movement, that motivates you or they kind of pull you along.

Because we believe in this, we're kind of evangelists for patient centered care, the individuals that are attracted to our organization, the caregivers that want to work there, come with a certain expectation on how we're going to perform and if we're not delivering on that promise, they don't mind slapping me in the side of the head and say, wait a minute, you're supposed to be patient centered and what you just did is inconsistent with that. So they keep you honest.

Remaining Energized & Driven in  Healthcare

Between community and our caregivers and patients saying, hey, this is supposed to be the Disneyland of hospitals, and Space Mountains not working today. You gotta fix that. Those things together I think really provide the impetus and the energy to continue this work. When I got into healthcare, I remember telling people that I was going to be a hospital administrator and people thought that was pretty boring.

Not very exciting, pretty mundane and I guess it could be if you approach it that way, if you didn't look for opportunities to really change. I like being a disruptor. I've never really accepted the status quo and as long as I have the ability to influence change, I find that sustaining, fulfilling and self-actualizing. And again, being part of an organization like this, that's what all of these people are. They're kind of change agents. So I think that's what, that's what keeps me going.

Person Centered Care at Planetree Inc, Susan B. Frampton, PhD

“One of the things that all people have the ability to do is to listen, to be a compassionate listener and to approach other human beings with that openness to whatever their experience is” S Frampton, PhD.

Susan Frampton, PhD is the president of Planetree International.

Planetree is both a philosophy of care, of patient centered care, of care that engages patients and families as a part of their care team. Planetree is also an organization that has advocated for the rights for patients and families to be more actively engaged in their own care for 40 years.

Technology & Humanism in Medicine

In terms of the future of patient centered care and Planetree’s role in that, I think that it will really be a challenge for us to look at the intersection of technology and the human touch and to not lose that human side of the care equation in this rush towards implementing more and more sophisticated technology.

There's some wonderful benefits that we have in store in terms of communications technology, in terms of artificial intelligence, but always we have to remember that at the center of the equation is a vulnerable human beings with human needs and that we have to make sure that we find a way to bridge technology and those human needs.

Healthcare Professionals Role in Person Centered Care

I think that the role of healthcare workers, healthcare professionals, advocates, in person centered care in the future as well as currently is absolutely essential. So, when we talk about patient and family engagement, we also are addressing staff engagement because the people that deliver that care, they're also at the center of the equation.

That's why we've really moved from talking about patient centered care to person centered care because they're also a part of the people that we have to make sure are supported, are engaged and involved so that they can give their very best to the patients. But in order to do that, we have to make sure that they're getting the support and the training that they need to do the very best that they can.

Empathy & Care Delivery

One of the things that all people have the ability to do is to listen and to be a compassionate listener. To approach other human beings with that openness to whatever their experience is. To understand that to try to meet other people where they're at and not to make judgments about things. To really try to be a little broader in the way that we approach other people so that again, we're trying to put ourselves in their shoes to understand what their experience, what their reality is.

I mean, that can be so diverse. It is a challenge because all of us have our own biases, whether we acknowledge them or not. We come from our own set of experiences and our own background and our own, training or what have you. But I think when we come together, particularly in healthcare, we have to challenge ourselves to think more broadly, to be more open and to be more compassionate listeners to the human beings that we're trying to support.

Patient Empowerment Initatives

So #careboss in many ways encapsulates what the whole philosophy of person centered care is, which is each of us has an opportunity to take more control of our own healthcare, to be advocates for ourselves, for our families, for our communities, and Careboss is a way of kind of energizing people to understand, you don't have to be a victim. You don't have to be the person who sits passively, that we do have power.

We have expertise about our own lived experience, about our own bodies, our own needs, and so it's really a movement to try to energize people to kind of take that power back to be the boss of their own care. To the extent that they're able to, where they're comfortable to. And so we're hoping that people will use that hashtag (#careboss) to share their experiences. To maybe give us their thoughts and perspectives about what it means to be in a space of more accountability for your own life, your own self, and what role you want to have in your own healthcare.

Humanism in Healthcare, Richard Levin, MD

"We are extremely interested in moving the power curve from a patriarchal classical circumstance in which doctors give orders & provide directions to patients to one in which the scientifically excellent care is developed together collaboratively". 

Dr. Richard Levin, is the President & C.E.O. of the Arnold P. Gold Foundation, a position he’s held since 2012.


Discussing Patient experience & humanism in medicine.

The relationship between doctors and patients has been existing and catalogued in the west for about 2,500 years and what is most important about it is the establishment of a human connection. The opportunity for the patient and doctor to be as close to one another as possible with trust, a sense of safety, a sense of the awesome responsibility that a doctor has to take care of a patient. Modern humanism and The Gold Foundation has been working on this problem for the last thirty years.

This is our 30th anniversary. The problem is more complex now because systems of care exist now where none existed previously. What do I mean? A system of care can identify a best practice which will involve the creation of a workflow; a series of work flows to manage an acute illness. Let's say that best practice was developed for the general population not for an individual and while compassion, integrity, empathy, responsibility, respect, resilience are all important attributes of someone who's practicing health care with humanism, humanism requires something more, something beyond patient centered care; A co-production of health. If there is a north star guiding the foundation's work right now, it's the recognition that we have become the champions of the human connection in health care over these 30 years.

We are extremely interested in moving the power curve from a patriarchal classical circumstance in which doctors give orders, provide directions to patients to one in which the scientifically excellent care is developed together collaboratively. A Nobel Prize in economics was awarded to the woman who originally came up with this notion that the best services will be co-produced by the receiver and the provider, not just the uni-directional in nature. Therefore, we are now going forward trying to make certain that in every health care encounter between a clinician and a patient we make sure that there is enough time, enough trust in the human connections so that the health care to be provided can be a collaborative decision of doctor and patient.

Co-Production of Health care

I'll give you an example of what I'm talking about; At the annual Jordan Cohen humanism lecture given at the annual meeting of the Association of American Medical Colleges last November, the talk was delivered by Don Berwick. The co-founder of the Institute for Health Care Improvement and for a while President Obama as director of CMS responsible for the development of Medicare and Medicaid services throughout the country. He has been a leader in the reform movement in health care. He suggested that the things that patients could be taught to do themselves so that they had a sense of greater autonomy in caring for themselves and dealing with an illness were much greater then we currently give patients the capability of understanding.

He showed several videos in a research context of a young man who had a genetic disorder that required a feeding with a nasogastric tube every night of his life while he slept. This young patient was taught to insert the nasogastric tube through the nose into the stomach by himself and he mastered it very easily. He then set up the infusion of the nutrients solution and took care of himself in that fashion.

Then he realized that one of the things that about illness that was really bothering the other pediatric patients he dealt with in the office when he saw them was this lack of autonomy, this lack of self-assurance capacity. He made a video to teach everyone how to do that, and it's very popular as it as an example of what the coproduction of health is actually about.

Things that the health care system provides but things as well including education in which the patient and family bring to the encounter critical elements that must be incorporated into their care plan. This is what we imagine will be the optimal patient experience in the mid-21st century and we are working with like minded partners across the country to try and make this a reality. When Dr. Berwick showed the video of this, there were gasps in an otherwise very sophisticated audience.

Chronic hemodialysis is extremely complicated and potentially dangerous. It requires making contact with an indwelling artery and vein with a catheter. Making certain that the site is sterile, making certain that the dialysis proceeds without to arrangements in the salt content of blood. It is quite complicated, but nothing beyond the sort of daily activities that any human might actually do. In a small study a number of people that have been taught to give themselves hemodialysis at home with the machinery necessary and all of the elements that make it safe for a given patient to do that. The sense of self actuation that allows a patient who is dealing with a chronic and serious illness, the failure of a major of working is astonishing and that's what the video revealed.

From the young child delivering nightly nasogastric nutrition to an older patient with renal failure kidney failure on chronic hemodialysis it is possible to involve the willing patient and family in entirely higher level of care and decision making than we have been used to in the past. Shifting that power curve from doctor, nurse, health system to more equality and collaboration with the patient and family we think it is a higher order of patient centric care.

Equipping Physicians for the Future of Medicine

Medicine has developed like any field over a very long period of time. There are few organizations, few fields that have survived 1,000 years of medicine and physicians have survived for 2,500 in the West if we mark the beginning with Hippocrates. For most of that time the only tool available to us was the surgical knife. We didn't have a drug of any variety that were in fact proven to be of value in the treatment of anything.

Penicillin became widely available in the 1940’s after being released first in 1928. And everything in the armamentarium, the CAT scans, the M.R.I. microsurgery, the ability to do robotic surgery, knowing about the anatomy of an internal problem but without cutting, all of that has happened in a very short period of time since the 1970. Physicians are trying to catch up to the changes that have occurred in technology all of which promised to return to them more time with the patient. That hasn't worked out as planned. The electronic health record unfortunately while developing rapidly is still a halfway technology. Most primary care physicians indicated in surveys that they spend two hours typing after seeing patients for every hour that they spend with patients in the hospital.

The annual survey by Johns Hopkins of a residence life indicates that probably 60% of their time is spent typing and those electronic health records at the moment are real time continuous wallets of practice issues, not the standard narrative that describes to anyone who wants to read it, including the patient and family, what the nature of the illness and the lives that they have led are actually like.

Barriers to Humanism in Medicine

We have extraordinary barriers, new ones of a disruptive technological age that have dramatically modified or what the experience of being ill what the experience of trying to remain healthy is actually like. We have the deep belief by most practitioners that molecular biology and the genomic age will indeed provide cures for most of the chronic illnesses that we encounter. That was a belief that began back at the beginning of this century and we now know that it's going to take years before those cures are available.

The notion that the cures and technology will take the place of the human connection is wrong. We need both and the touchstone for The Gold Foundation is scientifically excellent compassionate and collaborative care in every health care encounter. If we can reach that we truly will have an optimal health care system and the patient experience will be the best that it can be.

Medical education changed dramatically in the United States with the publication of the Flexner Report in about 1910. Abraham Flexner was an educator and was hired by the Carnegie Foundation to write a report about what medical education was like in North America. He spent a couple of years and visited most of the medical schools in Canada and the United States and published a report that showed that most medical schools were not up to the chore of producing doctors.

They were apprenticeships without a scientific method, the science underlying developing medicine was not emphasized or provided in this context. A better example of what medical education could be like were discovered at Hopkins University of Pennsylvania and Harvard using those as a model he proposed the system of medical education that we have in place now which is two years of deep inquiry into the sciences underlying the practice of medicine.

This was the method used in Europe in late 1880’s which is there are induced to revolution. We switch from wearing black coats to white coats, to identify the fact that we were practicing a new kind of science. The second two years of medical school were designed to be done in a teaching hospital. The requirement that he wrote was that those teaching hospitals have the same ethos, the same interests as universities that is education continued education of doctors.

That was the standard and remains the standard today and it has resulted in a kind of wonderful meritocracy which admits students based on their apparent capacities but does not take into account the E.Q. the emotional quotient of intelligence and does not take into account the inherent capacity of any applicant to communicate and communicate deeply with the patient in the model that we have discussed in the co-production of health.

The barriers to getting to optimal in terms of patient experience include everything from the selection process for medical students to the experience within medical school to the experience of becoming a doctor as a resident then and a young practitioner in which every element has been optimized not for the interaction with the patient, not to optimize the patient experience but to provide quality which is defined by efficiency and it's not enough.

We can do better and by taking a look at the epidemic of burnout of physicians and nurses because the systems are making administrators requirements on their time that should not be there all. Improving the health of the health care workforce and making that deep connection between health provider and patient in the coproduction of health. Those are the barriers that need to be overcome and it will take us probably another 25 years to get there. We've got a long way in defining what patient centered care looks like and I've suggested today that there's another step which is called the coproduction of health.

There are organizations in many countries that are approaching this problem logically and with a great deal of attention to what the experience of the patient is actually like. An organization known as PlaneTree which is headquartered in Connecticut has been accrediting hospital systems, health care systems, individual practices. I think in over 40 countries for 40 years this is their 40th anniversary and they have gone a long way to describing what is necessary to practice patient centered care from what must be provided architecturally all the way to the interactions that occur with patients at the most difficult moments of their lives.

Technology & Health Care

Technology has both allowed for revolution in the delivery of care and this will continue so that rather than spending six weeks in bed after experiencing a heart attack and having six months of physical therapy or disability after a hip replacement, patients without co-morbidities are sent home the day after a hip replacement. It's extraordinary the molecular cocktails that there are and will be available to treat cancers and other chronic illnesses are wonderful.

The electronic health record is transportable but it's not the design that is optimal. All of these technological wonders need now to be incorporated as physicians had done for these two millennia into a system of practice and care that shares the responsibility for the care to the extent possible with the patient and the family. I think it's not so far away, it's not so difficult for us to figure out how to do that as long as this is an accepted goal of the entire system with each health system contributing to it to the best that they can.