Focusing clinical collaboration on prevention
“It’s not enough to pull drowning victims out of the river. You have to walk upstream to find out who’s throwing them in.”
Physician and educator David Kilgore invoked that piece of wisdom from Episcopal bishop V. Gene Robinson to describe the current state of medicine in the United States — and the steps needed to drag the nation’s outmoded, costly and inefficient healthcare system into the 21st century. For doctors and other health providers, Kilgore noted in a panel discussion at the New York Times’ “Health for Tomorrow” conference, “walking upstream” means changing the focus of care from treating serious health complications after they occur to preventing them in the first place whenever possible.
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“We’re still stuck in the model from the first transformation of medicine, which did a great job with infectious disease, acute illness and injuries. But it’s not an effective model for chronic disease,” said Kilgore, clinical professor of family medicine at the University of California School of Medicine. “The river is full of drowning people, and we’re going to need a lot more than drugs or devices to usher in the second transformation of medicine.”
That transformation, he said, “has to ... focus on prevention, health and wellness.”
“We have more than two decades of research that clearly shows what keeps us healthy and what prevents chronic disease,” Kilgore said in a group presentation on the future of the doctor-patient relationship. “It’s the four foundational pillars of health: healthy diet and nutrition; exercise and activity; [attention to] mind/body [living conditions], including social support; and healthful sleep.”
Those factors, along with “toxin avoidance,” Kilgore said, are critical to long-term wellness. “These are powerful interventions that keep us alive longer, that help us have less disability and suffering for a lower-cost, greater-quality of life and less side effects. So the challenge for us as a profession and a society is how to move that second transformation ... into [community outpatient settings like] clinics, so that the primary care physician, instead of rushing from room to room ... is replaced by a new kind of healthcare team that surrounds and is part of that physician’s practice.”
That collaborative team of professionals, including nurses, pharmacists, clinic staff and nutritionists, Kilgore said, “then helps patients develop healthy lifestyle skills, self-management skills and self-efficacy.”
Driving the acute need for fundamental transformation in healthcare delivery, he added, is the fact that “in just the last 20 years, there’s just been an explosion of chronic disease. The incidence of diabetes has more than tripled. Sixty-eight percent of U.S. adults are now overweight or obese.”
“It’s a tsunami of diabetes and chronic disease,” Kilgore said. “And it’s completely changed what it means to be a family physician on the front lines. It very much seems like a ‘sick care’ system.”
Indeed, Kilgore said, “out of the $2.7 trillion [U.S. healthcare] budget, just 5% is spent on prevention and public health. We need to think about moving the whole enterprise upstream, targeting people even before they have that chronic disease. That means bringing tools for health and wellness to the workplace ... to schools, to community centers. It’s really incumbent on us to make sure patients have the tools they need for a healthy lifestyle.”
Other panelists agreed. “Despite lifestyle behaviors being primary contributors to most chronic diseases — which according to the CDC, are consuming at least 70% of our healthcare dollars — we don’t have a practice model that leads to achievable or sustainable behavior change,” said Karen Lawson, a physician who directs health coaching at the Center for Spirituality and Healing.
“I think there’s a missing provider ... who partners in a relationship-centered, client-driven process to facilitate and empower patients to achieve the health beliefs and behavior changes that they want,” Lawson said. “We call that person a health coach ... who applies their knowledge and skills to assist clients to mobilize their own internal strengths, to access their best external resources and to make the changes they want to make to optimize their well-being.”