What Are We Prepared to Do About Primary Care?

Everybody loves primary care.  Everyone notes how crucial it is to our health.  And, increasingly, it seems like everyone laments how it is in decline, especially in the United States. 

To paraphrase Sean Connery in The Untouchables, what are we prepared to do about it? 

Two recent studies bring focus on the situation: The Commonwealth Fund's International Health Policy Survey of Primary Care Physicians, and a study from Harvard Medical School researchers Characteristics of Americans With Primary Care and Changes Over Time, 2002-2015.  
Some highlights:

Credit: Photos.com

Commonwealth Fund

• The U.S. trailed all 10 other nations in primary care physicians who made home visits or provided after-hours arrangements;
• The U.S. was at or near the bottom in terms of receiving information on their patients from specialists or from emergency room visits;
• The U.S. was near the bottom in terms of coordinating patients with social services or community resources;
• Although the U.S. scores moderately well in Health IT options, it is among several nations where interoperability remains a challenge.

Their conclusion:

Improved technology alone will not suffice. Common ingredients of initiatives across countries include a strong commitment by government and other payers to primary care, the development of innovative care models, and active cooperation among professionals from the health care and social services sectors. 

 Harvard Medical School

• Since 2002, the percent of adult Americans with an established source of primary care has dropped from 77% to 75%;
• The decreases happened in all age brackets up to those in their 60's;
• For adults in their 30's, only 64% have such a source;
• "Those who are male, Latino, Black, Asian, uninsured, and living in the South are much less likely to have primary care."

Lead author David Levine, MD, warned:

Primary care is the thread that runs through the fabric of all health care, and this study demonstrates we are potentially slowly unweaving that fabric.  America is already behind the curve when it comes to primary care; this shows we are moving in the wrong direction.

 ----------

We have to keep in mind that, in the U.S., only about a third of physicians are primary care physicians,  and medical school students are less likely to choose the field, driven at least in part due to lower salaries.  Harvard's Dr. Levine noted: "Everywhere else in the world, 'primary care first' is the health care model." 

Not so much here.

There have been many efforts to change the situation, such as the Primary Care Medical Home, or proposals for medical school debt forgiveness for physicians who go into primary care.  Others see Direct Primary Care as a route to revitalize the role. 

The American Association of Medical Colleges wants the government to fund more primary care residency slots, even though the vast majority of internal medicine residents do not plan to go into internal medicine.   We could simply decide to pay primary care physicians more, but other specialties are unlikely to easily give up their income.

Many urge increased emphasis on "physician extenders," such as physician assistants and nurse practitioners.  Both fields (PAs and NPs) are booming.  In the U.S., there are more of these than there are primary care physicians, although not all of them work in primary care.

Credit: MarketWatch

Others see drugstores as the new home for primary care.  Following its acquisition of Aetna, CVS is betting big on its in-store HealthHubs, hoping to have 1,500 "concierge-style in-store centers" by the end of 2021.  United HealthCare is teaming up with Walgreens, as is Humana. 

Forbes called this strategy "Dr. Drugstore." 

So far, though, "retail clinics" have not demonstrated that they save money, substitute for more expensive care, increase access, or improve patients' health.  But, in our healthcare system, what does?

The stats are telling us that we're increasingly not establishing primary care relationships.  The stats also suggest that our health is on the decline, with half of us expected to be obese within ten years and with declining mortality.  More primary care could help, but perhaps not necessarily in the way we are currently thinking about it. 

Our health doesn't happen in medical offices, and cannot always be fully discerned in them.  Where we live, how we live, even with whom we live and socialize bear greatly on our health.  Primary care belongs where we live, not where we visit.

Not even drugstores. 

I propose two significant changes to help make primary care relevant in the 21st century:

Virtual Care:
I wrote a longer piece on this earlier in the year.  In short, it's a disgrace that we've put so many hurdles on telemedicine, and that it continues to be so underused.  It is widely available in health plans, but rarely practiced by physicians nor by patients.  Instead, we still mostly go to our doctors offices, to ERs, or perhaps now to drugstores.

Credit: Harvard Health Blog

A televisit should be the first course of action for non-emergencies.  We must remove regulatory and reimbursement barriers, and incent patients to take advantage of the speed and convenience of the option. 

Moreover, as AI options for diagnoses and advice quickly become more viable, we can use them to triage our needs, help assure continuity with physicians, and eventually reduce the need to talk to a human.

Rethink Primary Care Physician:
We need a new kind of primary care physician. 

Other countries have shorter periods of medical education; why don't we do that specifically for primary care physicians?  Shouldn't we train primary care physicians more on, say, social determinants of health, social supports, behavior moderation techniques, and less on topics of more importance to other specialties?  It's not that primary care physicians need to know less than other specialties as it is that they need to know different things. 

We should train a lot of them, and make them easily available.  Even for home visits.

A village doctor in China.  Credit: CDC

In China they call them "village doctors" (an improvement over the original "barefoot doctors").  China is also emphasizing AI "doctors."  They know they have an access and capacity problem, as do we, but they're addressing it creatively.  We ignore their lessons at our own risk.

Some might worry about a status reduction relative to other specialties -- "they're not real doctors..." -- but, if so, that's our fault.  They'd be the ones who know our health best, and deal with it the most.

----------

Neither of these suggestions would be trivial to bring about.  Both would face significant opposition from the status quo interests.  But those interests are currently strangling primary care, and adversely impacting our health. 

Time to do something different in primary care. 

Customer Service -- Bah, Humbug!

It is the holiday season.  Time for family, being grateful for what you have, and surprises, both good and bad.  Also time for lots of waiting, spending more than you planned, dealing with many strangers, and some frustrating service. 

In other words, a lot like most days in healthcare. 

In The Conversation. Professors Anthony Dukes and Xi Zhu make the argument that, contrary to what we might think, good customer service is not a prerequisite to business success.  In fact, they say: "Some of the most hated companies in the U.S. are also the most profitable."   Or, as Fast Company sub-headlined it in their version of the article: "Unfortunately for you, bad customer service is good for business."

Their research specifically looked at how companies made it difficult for customers to obtain refunds.  They found: "Many complaint processes are actually designed to help companies retain profits by limiting the number of customers who can successfully resolve their complaints."

Forcing customers to overcome chatbots, phone trees, and Level 1 human representatives without authority to fix the customers' problems are all part of the strategy.  Companies even use AI to gauge just how angry a caller is; only if the customer is deemed to be a risk of ceasing to be a customer does he/she/they get transferred to someone who can actually help. 

As they say:

This allows companies to exploit customers’ individual differences in age, race and gender so that only the “squeakiest wheels” are compensated...This all suggests that the tiered process may hit vulnerable groups in our society harder. Therefore, elderly customers and some minority groups will be less inclined to obtain a refund.

The professors cite Comcast and United Airlines as customers who brag about top-notch customer service even as customers routinely cite them for their poor service. 

It shouldn't come as a surprise, but they note that "in markets without much competition, companies are more likely to implement a tiered complaint process and profit from the reduced payouts to customers."

And we're back to healthcare. 

One would think that an industry built on caring, and, in fact, filled with many caring professionals, would put customer service at a premium.  "Treat every patient as you would a family member" is the kind of attitude we'd expect.  But that is not the reality most of us experience.

Healthcare is often maddeningly opaque.  Many of us don't quite understand the terminology, what our diagnosis really means or exactly what our treatment will be, what everything/anything will cost, and how much our health coverage will pay.  Most of our time dealing with healthcare entities is spent waiting -- on the phone, in waiting rooms, for treatments.  We rarely know how long the wait will be or exactly what will happen next.

We might ask about costs in advance, but good luck.  The healthcare professional we ask is most likely to admit they don't know, or only have an approximation and only for their specific services, not others that are included in the treatment plan.  And, of course, the cost will differ by where you receive services, who is treating you, and which health plan you have. 

If we have questions about what has happened/is happening/might happen, most likely we'll spend more time waiting to get an answer, one which may or not prove helpful. 

Should we decide to complain, well, to whom should we?  We've come to accept a low bar for customer service in healthcare.  We might get apologies but not are likely to get action.  Even when we suspect medical errors or incompetence, complaining to the state medical board or filing a medical malpractice claim are both processes that often end up being fruitless. 

How many Bill of the Month stories does Kaiser Health News have to run before healthcare organizations actually change their billing practices?  How many times does ProPublica have to report on conflicts of interest for healthcare professionals before they take it seriously?  How many times does NPR have to report on healthcare organizations suing patients before they become too ashamed to do it? How many more health system settlements for anti-competitive behavior do we need to get them to, you know, stop the anti-competitive behavior? 

Most importantly, why are there still so many medical errors? 

The next time you can't get through to a customer service representative at your health plan, or the next time you can't get timely help as an inpatient, find out how much the CEOs of the health plan and hospital, respectively, make annually, and it will be clear how much they value customer service. 

Healthcare is good at charging a lot of money, and at making a lot of money, but no so good at using that money to deliver a good customer service experience for the people who use it.  Despite that, we trust our doctors, consider our hospitals community anchors, and even are pretty happy with our health plans. 

It's as if we're in an emotionally abusive relationship with the healthcare system.  It doesn't treat us well, but we stick with it.  We complain about it to friends and family, but we still love things about it.   We fool ourselves into believing it will change for the better.  And we view ourselves as being too dependent to ever leave it. 

Let's face it: we're a long way from ensuring quality care.  Our health disparities are shocking.  We're not getting better at preventing patient harm.   We constantly worry about affordability.  All that is shameful, and must be addressed. 

But, honestly, isn't the very least that our healthcare system could do is to provide excellent customer service?  At this point, most of us would probably settle for "good" customer service -- for being treated fairly, for being treated like we are listened to.   For being seen as people who need help, rather than as sources of revenue.   

We want straight answers, responsive service, and appreciation for our time and money. 

If Ebenezer Scrooge can reform and get Tiny Tim the health care he needed, perhaps our healthcare system will experience its own Christmas Carol revelations.  As Tiny Tim said, "God bless us, every one."

Robots for Mom...Or Me

Last week in an The New York Times op-ed, author Maggie Jackson asked the question: Would You Let a Robot Take Care of Your Mother?  Ms. Jackson notes how robots are increasingly being used for assisting in the lives of seniors, which she understands but is concerned about.  "At stake," she says, "is the future of what it means to be human, and what it means to care."

I get her concern.  As I've written about before, we trust robots too easily and tend to feel empathy for them.  We can even fall in love or hurt them.  In other words, we end up treating them like people.  As Matthias Scheutz, a Tufts University roboticist, told Ms. Jackson, "What I find morally dubious is to push the social aspect of these machines when it’s just a facade, a puppet. It’s deception technology."

But, yeah, I'd have let a robot take care of my mom, and I hope robots will be there to take care of me.

Robear  Credit: Riken

My mother, alas, is no longer alive.  She lived to her mid-90's, and her last few years were not atypical.  She went from walking to cane to walker to wheelchair.  She went from driving to needing a driver to take her on errands to having someone do all her errands.  She went from visiting friends to being dependent on friends visiting to sitting at mealtimes with strangers.  She went from home to condo to retirement community to assisting living.  

She went from being independent to having a caregiver come in a few times a week to needing round-the-clock attention.  And by "round-the-clock" I mean checking in on a schedule or in response to her call button, usually at some significant delay.

None of her children lived close, so phone calls and periodic visits were the time we had with her.  The television and the radio became her most common companions. 

Some of her caregivers were caring far beyond the call of duty.  Most did their job professionally.  A few of them she didn't like or was even afraid of.  Most importantly, all of them were there primarily to help her accomplish tasks, and none of them was always there when she needed or wanted them. 

It's too late for my mother, but as I get closer to my senior years, I hope there will be plenty of robots.  Here are some ways they could help:

Exosuits:  As walking and other routine tasks become more difficult, I hope my failing body is augmented by an exosuit.  This is something that the military is all over, but applications for seniors have been touted for years as well.  We talk about "wearables" and mostly mean smartwatches or maybe IoT clothing, but some see robotics built into clothing as well.

See, for example:

We're not there yet, but the progress in just a few years is encouraging.  Good-bye to those walkers and wheelchairs, goodbye to constant fear of falling.  Hello staying safely in one's own home.

Companions: too many seniors outlive their spouses, their friends, their neighbors, and don't live close to their children (who have competing demands in their own lives).  More seniors than we'd care to admit spend too much of their time alone. 

We already have a suite of "companion" robots.  They remind seniors to take pills, help answer simple questions, and coordinate with healthcare providers.  There is Mabu, by Catalia Health, whom Ms. Jackson mentions, or Zora, as well as many others.  Toyota has a whole suite of "partner robots,"

Cory Kidd, the founder and CEO of Catalia Health, explained to MIT News why robots like Mabu could be helpful in care management programs: "What I found was when we used an interactive robot that you could look in the eye and share the same physical space with, you got the same psychological effects as face-to-face interaction." 

As promising as these are, though, Ms. Jackson urges that humans should always know they're dealing with a robot or algorithm, and that it not interfere with human relationships. 

Caregivers: the above two categories are important, but the thing that is hardest to find humans for are the nitty-gritty tasks involved in caregiving.  Tasks like feeding, bathing, transfering, assistance with toileting, and cleaning.  Those involve human contact, often with frail individuals and for very personal needs. 

We have robot maids, beds that can make themselves, robotic shower systems, robots that can clean bathrooms, and robots that can help people transfer in and out of bed or wheelchair.  We may not yet have robots that can directly assist with toileting, but it is only a matter of time. 

We're going to need them.

------------

It has been pointed out before, but in this month's Harvard Magazine Jonathon Shaw discusses the "coming eldercare tsunami."  It will hit Japan first, then China, and soon enough the U.S. and Western Europe.  There simply will not be enough younger people to take care of the elderly populations -- financially or directly.

The Pew Foundation reported in 2017 that 59% of Americans were not interested in a robot caregiver for themselves or for a family member, but 59% also see it as a realistic prospect.  One respondent said: "A robot would never fatigue, would never get emotional or angry. They have no ego, they would just care for the individual."  Another warned: "The main problem with the elderly is that they get confused. If the robot malfunctions, an elderly person would not be able to manage that situation adequately.”

Ms. Jackson, and many respondents in the Pew study, argue that human interaction and empathy is preferable, but the simple fact is that it is not always convenient, affordable, or possible.  When Boomers start needing more support, we're not going to be happy to rely on underpaid caregivers to help us when they can. 

Fortunately, Boomers and, even more, the generations who follow, are used to technology.  We love our smartphones and are getting used to smart watches, smart TVs, smart homes, and smart cars.  We'll be ready for smart caregiving robots, in all the forms they may take.

The caregiving robots will be too late for my mom, but hopefully not for your mom, or for you and me. 

Down the Rabbit Hole of DOT

I'm a sucker for stories about new uses of DNA.  Talk about DNA for data storage, and I'm interested.   Start developing DNA-based "lifelike" mechanisms that could be used for robots, and I'm intrigued.  Use DNA for computing and I'm excited.  But 3D print a plastic bunny that includes DNA "blueprints" on how to 3D print itself, well, that's irresistible.

We talk a lot about the Internet-of-Things (IoT), but it may be time for the "DNA-of-Things" (DOT).

Researchers from the Swiss Federal Institute of Technology (ETH Zurich) and the Erlich Lab did just that, describing their efforts in a paper in Nature Biotechnology.  They translated the 3D printing instructions for the rabbit in a synthetic DNA sequence, encoded it onto tiny glass beads, and embedded those into the rabbit.  

Credit: ETH Zurich/Erlich Lab

 As one of the authors said: "Just like real rabbits, our rabbit also carries its own blueprint,"  Fittingly, the first 3D printed object that encodes itself is not just any generic rabbit, but, rather, the famous Stanford bunny, which has been widely used in computer graphics 3D testing for 25 years.  

As proof of concept, the researchers have replicated the bunny into the 5th generation using the encoded DNA.  One of the authors, Yaniv Erlich, says, presumably tongue-in-cheek: "Plus, you know, you pull rabbits out of the hat."  

We have to remember that DNA is not just a dense medium for data storage, it is potentially hyper-dense.  Each bunny, for example, carries 370 million copies of its instructions, and we're just getting started.  

Dr. Erlick tweeted:

All other known forms of storage have a fixed geometry: a hard drive has to look like a hard drive, a CD like a CD. You can't change the form without losing information.  DNA is currently the only data storage medium that can also exist as a liquid, which allows us to insert it into objects of any shape.

Here is a video of their process:

This is not just playing around.  The authors describe their efforts as a "'DNA-of-things’ (DoT) storage architecture to produce materials with immutable memory."  Drew Endy, a Stanford bioengineering professor, told IEEE Spectrum their work:

...is incredibly interesting from a cultural perspective.  Imagine a societal norm in which every object must encode the instructions for making the object.  Given the incredible information density of DNA data storage, such information could, in some commonplace objects such as refrigerators, also include a fully unabridged guide to rebuilding all of civilization.

Admittedly, the process is currently neither cheap nor easily available.  You need a DNA synthesizer and 3D printer, for example.  Even with the technology, the researchers figure replicating their first bunny cost about $2,500, with most of that cost in the synthesizing.  However, both technologies should radically come down in cost over the next few years.  The researchers hope to make DNA storage an "everyday technology."

We haven't really had time to imagine all the possibilities.  Sriram Kosuri of UCLA  told New Scientist: : "You can imagine a system where everything is tagged with small bits of useful information.  What’s cool about this work is that they show that is doable today, and it seems pretty reliable."  Calin Plesa of the University of Oregon added:  "Any potential application is still likely years away, but this study is certain to inspire creative uses we can’t predict right now,"

The researchers certainly believe that DNA-of-Things (DOT) has big potential.  They describe some possibilities:

DoT could be applied to store electronic health records in medical implants, to hide data in everyday objects (steganography) and to manufacture objects containing their own blueprint. It may also facilitate the development of self-replicating machines.

I'm particularly fascinated by the possible applications to healthcare -- some of which the authors explicitly mention.  Co-author Robert Glass explained that "this technology could be used to mark medications or construction materials...Information about their quality could be stored directly in the medication or material itself. This means medical supervisory authorities could read test results from production quality control directly from the product."

Credit: Shannon May/The Scientist

Similarly, Discover Magazine reports "the research team thinks this technique could be well-suited for even smaller devices, like medical implants. A patient's dental history could be compacted into their tooth filling, for example." 

Professor Erlich has suggested the idea of "DNA-aware homes—faucets that test for harmful pathogens and toilets that report back on the health of their users’ gut microbiome."  

I speculated three years ago about using DNA storage to become our own medical records, and the bunny suggests that the idea is now not so far-fetched. 

Sixty years after its discovery, we're starting to meaningfully interpret and use DNA.  Thirty-five years after its invention we're finding more and more ways to use 3D printing.  But the ETH Zurich/Erich Lab research points to a future that changes how we think of both, as well as our concepts of data storage and perhaps even data itself. 

We're just starting to explore the possibilities of Internet-of-Things, and now DOT comes along to radically expand what IoT can do and how it can do it.  Healthcare is not going to be the only aspect of our lives that is likely to be impacted by DOT, but it is going to be one of them.  

Like bunnies, uses for DOT are only going to multiply.  

Let's Place Some Big Bets

Several articles caught my attention this week.  None was specifically healthcare-related, but each, in their own way, apply.  They all were about challenging our assumptions and gambling on a different course.

Let's start with David Harrison's article in The Wall Street Journal about highways.  Yes, highways.  Most of us have grown up taking the interstate highway system as a given.  Some of us remember parts of it being built, and probably all of us have witnessed portions of it being repaired/expanded.  But too few of us remember how the original construction of many urban stretches wiped out whole neighborhoods. 

As Professor Norman Garrick told Mr. Harrison:

The freeways were put in to divide the black neighborhoods from the white neighborhoods or they were put straight through the center of the black neighborhoods and basically destroyed them.

Mr. Harrison reports how several cities -- such as Rochester (NY), Portland (OR), and Milwaukee -- are trying to reverse this by removing existing highways and reclaiming the land they occupied.  The Milwaukee planning director who oversaw the efforts there claimed:  "We’ve showed that when you take the highway out of the city it gets better. It’s that simple."

Who'd have thought?

The second article was from Laura L. Carstensen, of Stanford's Center on Longevity.  She states simply: "It’s time to get serious about a major redesign of life."  Our education, employment, healthcare, and retirement systems all still act as though we'll only live long enough for, at most, a few years of retirement.  As Professor Carstensen says: "Yet as longevity surged, culture didn’t keep up."

The Stanford Longevity Center has an initiative The New Map of Life that tries to rethink all stages of our lives.  It would require major changes.  "The challenges demand extraordinary social, scientific and educational investments," Professor Carstensen admits.  "The opportunities are even more extraordinary.... The greatest risk of failure is setting the bar too low."

As we often do.

The third and final article is from Sam Walker, also in The Wall Street Journal, on the "dying art of the Big Bet."  He uses the example, not surprisingly, of Elon Musk, with his recent electric truck, which, as Mr. Musk bragged at the truck's unveiling, "Doesn’t look like anything else." 

It's not surprising.  Mr. Musk described his approach to market research: “I do zero market research whatsoever."

Much as Elon Musk is famous for gambling on his instincts, in an era of Big Data, Mr. Walker argues, companies "don’t make bets. Before making operational changes, they run experiments to determine the outcome."  He cities the famous quote from Albert Einstein about solving problems:

Mr. Walker concludes: "Put simply, today’s geniuses study problems. Only suckers make bets." 

Call me a sucker. I'm all for rebuilding neighborhoods by tearing up highways, for redesigning the way we live, and for sometimes throwing out the data in order to place some big bets.  

When you read "highways," think hospitals and nursing homes, and when tearing them down might make the most sense.  When you think about redesigning life, think about Dr. Arthur Kleinman calling for us to change our disease-based healthcare system to an illness-based healthcare system that focuses more on "how to live a life disrupted by a disabling illness."

And when we think about market research and Big Data, think about Henry Ford's (possibly apocryphal) quote: 

Most of our healthcare innovations and reforms take the existing healthcare system as a given and try to build upon it in some way.  They add more on-ramps to the healthcare superhighway, widen its lanes, try to smooth the pavements, maybe even automate our driving on it.  But sometimes we need to tear the highway down.  

Here, in brief, are some big bets I'd like to see someone take on:

The end of medicine: Forget procedures.  Forget drugs.  Forget the practice of medicine as we know it.  Instead, we'd each have an army of nanobots inside us constantly repairing, restoring, revitalizing -- addressing most problems before they manifest and repairing ones that do.

The broader perspective: Most of our medical care is based on human anatomy and human biology, but we've come to realize that we live with a microbiome that may outnumber our cells by 10 to 1.  We can't be healthy without the "right" microbiome, so we need to totally reorient our approaches to medical care to emphasize the health of our totality, not just the "human" portion.  

Redefining healthcare professionals: We have a cornucopia of healthcare professionals.  M.D.s and D.O.s, pharmacists, dentists, nurses, optometrists, podiatrists, chiropractors, and so on.  Specialties beget sub-specialties beget sub-sub-specialties.  They're like the blind men and the elephant, only we're the elephant.  

In the not-too-distant future, though, most expertise will come from A.I. and most manual interventions will come from robots, so we should be thinking about what the uniquely human role in health care is, and how to prepare people for that role.  

Basic needs first: Amid all the debate about MedicareForAll, I want to see someone say: not one more dollar for medical care until every person has enough of the right food, lives in safe housing, has a healthy environment, has meaningful access to appropriate education, and gets the support they need for their daily activities.  

It may mean fewer of those million dollar drugs, more limits on "heroic" efforts to maintain life, and less hospital construction, but when people are starving and/or homeless literally in the shadows of new healthcare buildings, we know our priorities have gotten confused.  

------------

Most big bets don't pay off.  Most people like to bet on a sure thing, or at least on things that look like they have a good return.  Most people see the future very much like the present, only moreso.  But we're not going to increment our way out of the healthcare mess we find ourselves in.

So, yeah, I'm a sucker for solutions that don't look like existing healthcare solutions.  I'm a sucker for new approaches to old problems.  I'm a sucker for things that look like we borrowed them from the 22th century, rather than iterating them from the 20th.  

Any healthcare gamblers out there?