We tend to think of medical breakthroughs arriving in the form of a radically effective pill or a flawless diagnostic tool. But what if the next great innovation we need is a different way of interacting with patients?
<p> It’s not as far-fetched as it might sound. Long before the advent of anesthesia or chemotherapy, conversation was medicine’s backbone technology. Asking the right questions of patients and discerning what to do with that information were key medical skills.</p><p> In the modern era, medicine’s leading technologies changed. The advent of pharmaceuticals, surgery, vaccinations, and public health helped the profession make great strides against the acute, infectious diseases that once caused the bulk of mortality.</p><p> Today, though, most people in the Western world struggle against chronic diseases that can’t be solved with a quick fix. In fact, the most effective way to address many of them are changes in diet and lifestyle — exactly the factors ancient physicians sought to influence as they spoke with patients. But how can today’s doctors achieve effective rapport with patients when their average encounter lasts fifteen minutes or less?</p><p> We may find clues in an unexpected place. In 2012, <a href="http://www.theinsightlabs.org/healthcare">Insight Labs</a> (the philanthropic think tank where I work) initiated a project in conjunction with <a href="http://www.familyvan.org/">The Family Van</a>, a mobile health program operated by Harvard Medical School. Mobile health clinics achieve remarkable results in underserved communities across the nation. Using the <a href="http://www.mobilehealthmap.org/">Mobile Health Map</a> tool, these programs can demonstrate that every dollar spent on the preventative services they offer saves the system at least 18 dollars down the road. Yet we learned that other actors in the system rarely recognizes mobile clinics’ value.</p><p> The interdisciplinary <a href="http://www.theinsightlabs.org/labs/how-can-we-do-more-with-mobile-care/">group</a> we convened in conjunction with Family Van’s leaders (we call it a “Lab”) helped us understand why — hospitals and clinics never directly feel the impact of patients who were never sick and thus never showed up at the emergency room. While they may be grateful in the abstract, they have so many other problems to deal with that building strong relationships that sustain mobile clinic programs is not a priority. Instead, the thinkers we convened advised mobile clinics to provide something that would help their colleagues solve the problems in front of their noses.</p><p> In this new context, we saw that the most important resource mobile clinics could provide the rest of the system was not prevention, but knowledge.</p><p> There are three areas in which these clinics are potentially ahead of the curve. First, they better understand the problem of adherence — the reasons why patients do and do not stick to the treatments health care providers suggest. That’s vital information as the Affordable Care Act forces providers to invest in medical advice that sticks. Second, they better understand the epidemiology of the communities surrounding hospitals and clinics. As Family Van’s Jennifer Bennet observed, the diseases that will be treated at emergency rooms show up at the vans first. Third, their rich interactions with the people they serve provide a potential forum for patients to suggest design improvements to various treatments or devices (or perhaps just as importantly, explain the specific ways in which existing options fail).</p><p> Following the session at Cambridge, Insight Labs sought to further explore these three ways in which mobile clinics’ knowledge could earn them greater respect from other healthcare institutions. So we initiated a series of conversations around these themes. In one recent <a href="http://www.theinsightlabs.org/research/adhere-to-the-human-element/">panel</a>, we talked to two innovators in the area of adherence — asthma researcher <a href="http://davidvansickle.com/">David Van Sickle</a> of <a href="http://propellerhealth.com/">Propeller Health</a> and electronic payments entrepreneur Samuel Whitaker of <a href="http://greenphire.com/home">Greenphire</a>. In conversation with Anthony Vavasis (a New York-based mobile practitioner and board chair of the <a href="http://www.mobilehealthclinicsnetwork.org/">Mobile Health Clinics Association</a>) we discovered something surprising. The most valuable thing other health care providers may be able to learn from mobile is not <em>how </em>a mobile clinic operates or <em>where </em>it goes, but <em>who</em> is there and <em>how</em> they converse.</p><p> The breakthrough came by asking what means might most efficiently reproduce the conditions that help mobile clinics achieve their results. Initially, that seems almost impossible. The best clinics do their work by engaging with specific vulnerable populations in the neighborhoods where they live. As Vavasis said, these are “people who may have a well-founded distrust of the system and may not be inclined to engage in any medical care anywhere.” The best results are achieved by employing community health workers with whom the target patients can identify in specific ways. For example, Vavasis observed that when he and his team do HIV/AIDS outreach to homeless youth in New York, more transgender patients show up when a transgender health worker is on the vehicle.</p><p> That sort of demographic matching may seem impossible to achieve in a busy emergency room (not to say it shouldn’t be tried). Yet Van Sickle and Whitaker said this “human element” is exactly what they would study to extract wisdom from the mobile clinic model. Specifically, they said they would look at the conversational styles providers and outreach workers use with patients on the van.</p><p> Now imagine that we could assign a very attentive graduate student to every mobile clinic. With enough data from a variety of settings, researchers could hypothetically identify the crucial ways in which these health workers help patients feel safe, empowered, and open to medical advice. Whitaker even suggested that the same sort of technology that allows companies to improve customer service could be adapted to understand variations on the provider-patient conversation. Those variations could then be linked to various adherence outcomes. It’s a remarkable way of thinking about our newfound computing power that could make medicine more personal, not less.</p><p> These research paths are of course speculative, but the wisdom underlying them is not. The way in which doctors and nurses interact with patients doesn’t just affect their care — in many cases, it <em>is</em> their care. For us to neglect the design of that care in favor of the latest medical gizmo is a disservice to the sick. </p><p> In that vein, perhaps even waiting on technology to help us parse medical conversation is a mistake. As Vavasis suggested near the end of our discussion, practitioners who work in more conventional settings could learn a lot about how they interact with patients simply by talking to their colleagues who’ve spent some time in a van. By collaborating with those on the fringes of today’s system, they could innovate in a way that resonates with the best traditions of medicine. They could achieve better results tomorrow inspired by the skills of yesterday’s care.</p><p> <em>The full text of the Insight Labs conversation about adherence and mobile clinics is available <a href="http://www.theinsightlabs.org/research/adhere-to-the-human-element/">here</a>. It’s free not only to read, but to quote, cite, redistribute, etc. under a Creative Commons license. </em></p>
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