April 9th, 2009
Editor’s Note: Health Affairs is proud to be a media partner for the Health 2.0 Meets Ix conference, which will take place April 22 and 23 in Boston, Massachusetts. As part of the lead-up to the conference, which will focus on the interplay between the Health 2.0 and information therapy (Ix) movements, Health Affairs Blog and other participating blogs will feature a series of posts discussing ideas that will be featured at the conference.
The post below by Rushika Fernandopulle provides another physician perspective on the same question addressed by John Halamka earlier this week: How do we build Health 2.0 and Ix into the delivery system? Both Fernandopulle and Halamka will participate in a debate on this topic in Boston. The first post in the series described the background and main themes of the Health 2.0 and Ix movements.
I am an internist who has been working for the last 5 years to design, build, and test radically new models of delivering primary care to improve experience, outcomes, and affordability of care. I currently serve as medical director of one of our redesigned practices in Atlantic City, NJ.
Yesterday afternoon, Mr. Santos, a 53-year-old Hispanic doorman at a local hotel, came in to see me quite visibly distraught. His prior primary care doctor had, without asking him or discussing the issue, checked a PSA (prostate-specific antigen) test as part of his “routine” blood tests, and the results were mildly positive (6.5). He was told, “Your screen for prostate cancer was positive, you need to see a urologist right away to have it taken care of.” All he heard, of course, was “cancer” and “positive” in the same sentence.
Before Mr. Santos had time to even form the first of the dozens of questions he had, the doctor had already stridden out the door. Over the next few weeks, Mr. Santos went online to read about PSA and prostate cancer (which yielded over 6 million pages on Google), and started talking to his friends at work about the issue. What he surmised, quite correctly, is that the way forward for him was not at all clear, and that instead of finding answers, he only had more (but better) questions. What really was his chance of having prostate cancer? If he did, what really were the benefits of catching it so early? Were the risks of the biopsies worth this benefit? What were his other choices?
Mr. Santos’s prior PCP clearly operated under the old-school paternalistic doctor model; I, the doctor, will manage your health; just leave it up to me. While this works well for some patients in some situations, for many, including Mr. Santos in this case, it clearly does not. More of health care than we care to admit lies in the gray area like the PSA issue here; there is disagreement in the science; and, even more importantly, patients’ values and goals make a real difference. Also, particularly for chronic conditions, even if we wanted to, we as doctors cannot manage our patients’ health. At most, a patient will spend a few elapsed hours a year with us, leaving more than 8,750 hours not in our offices, and this is when all the real decisions need to be made.
The Health 2.0 movement provides a radical alternative to this old model where the physician monopolizes information and decision making. Here patients learn from each other and help each other make the right decision for themselves. This has always happened to some extent around the water cooler and among friends discussing their health problems, but the Web has allowed virtual such communities to form and conversations to occur, and magnifies the potential of such interactions.
This is what Mr Santos turned to after leaving his old PCP’s office. The problem is that medicine is very variable, and one patient’s experience may or may not apply to yours. Also, there is no rigorous science filter among voices heard on the Web or around the water cooler, and many of the 6.1 million Web sites indexed by Google give misleading or even dangerous advice.
Information therapy, at its best, is a way to steer a sensible middle course between these two extremes. It allows a patient to work with a doctor (or other trusted health professional) to learn from information sources and other patients, and then filter and process this information with the application of the best science available to best meet their own goals and values. A good, experienced clinician has seen many cases of the same thing and can help a patient put their information they learn into perspective.
The Patient-Physician Relationship: Finding The Right Fit For Each Patient And Each Case
For our health care system to truly best meet the needs of our patients, it needs to combine all of these approaches depending on the patient’s wishes and the particular situation. When one is having a massive MI (heart attack), one simply needs a great doctor to take charge and reopen the blocked artery. When one is contemplating dietary changes or creating an exercise regimen, then turning to communities of like-minded patients (framed broadly as Health 2.0) is an appropriate approach. However, most of health care lies between these extremes, and information therapy — where a trusted clinician helps guide the patient to the right information and mediates and puts into perspective the knowledge gained from communities — is likely the right choice for most.
This is what I did with Mr. Santos. We spent 30 minutes together discussing what he had learned and, perhaps more importantly, meshed this with what his goals and values were in terms of his health. In the end we decided together to recheck his PSA in 6 months to see whether it was rising or falling, I pointed him to a number of other resources to learn more about his choices, and we would decide after this whether to proceed with a biopsy or not. This process may have taken longer than what his prior doctor had spent, but I believe it clearly led to a better outcome for both the patient and the health care system as a whole. We all deserve no less.Email This Post Print This Post
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