July is one year since SETMA achieved National Committee for Quality Assurance (NCQA) recognition as a Patient-Centered Medical Home and Accreditation Association for Ambulatory Health Care (AAAHC) accreditation as a medical home and for ambulatory care. It is also the first month in which clinics can begin applying for accreditation by The Joint Commission (JACHO) as a medical home. Currently, to my knowledge, SETMA is the only organization to have dual medical home designation. SETMA anticipates applying for Joint Commission accreditation as a medical home in January 2012; assuming success in that process, we will certainly be the only clinic to have NCQA, AAAHC and Joint Commission medical home credentials. This will allow us to learn from the different approaches and to comment on our recommendations for the best way in which to transform a practice into a medical home.
July, 2011, is 27 months since SETMA began the process of transforming our practice into a medical home on February 16, 2009. On that date, five SETMA colleagues attended their first medical home lecture. Over the following ten weeks, this column was occupied with our growing understanding of medical home; those articles are published on our website at www.setma.com.
After functioning as a medical home for a year, it seems appropriate to re-examine our understanding of the concepts and principles of medical home and to access where we think we are in this process. This will include an honest assessment of what we think we understand and of what we think we still need to learn. This second series of medical home articles begins with "Medical Home - The Movie." It will be followed by articles on:
- Sign post for health
- Care Continuity
- Care Coordination
- Care Transitions
- Care Plans and Treatment Plan
- The Medical Home Team
- And others
While on vacation this summer, I saw the movie People Will Talk. It is the story of a physician who is opposed by a colleague. Each has a different vision of healthcare. Released in 1951, People Will Talk portrays a physician who sees people as more than a disease and medicine as more than a science. The movie is a comedy, a musical, a drama and a suspense story all rolled into one. There are elements of the characters lives which are not consistent with modern medicine. The main characters smoke, but this reminds us that the tobacco industry used movies and television as vehicles of addiction. The doctor's bride-to-be shoots herself, aiming for her heart, misses and without complication walks out of the hospital the same day as surgery. Of course that is not possible. A cadaver in the anatomy lecture hall has pink skin, make-up and well coiffed hair. But, in spite of these contradictions and absurdities, there is much to learn from this picture about patient-centered medical home.
The movie begins with a printed narrative which prepares you for the story. My favorite movies start this way, and along with narration and theme music, movies establish a great pattern for live. The narrative states:
"This will be part of the story of Noah Praetorius M.D. That is not his real name. Of course...There may be some who will claim to have identified Dr. Praetorius. At once, there may be some who will reject the possibility that such a doctor lives, or could have lived. And, there may be some who will hope that if he hasn't, or doesn't, he most certainly should.
"Our story is also -- always with high regard -- about Medicine and the Medical Profession. Respectfully, therefore, with humble gratitude, this film is dedicated to one who has inspired man's unending battle against Death, and without whom that battle is never won.... The patient."
Immediately, you know that this story is going to focus on "the patient," and that is also the focus of medical home. The following vignettes from the movie expand on the idea of the patient being the central focus and the most important person in medicine.
The movie opens with Dr. Praetorius waiting for his opponent to arrive in the medical school's anatomy lecture hall. As the medical students sit waiting, Praetorius says, "I cannot give you the lecture which you came to hear and I am not sure that you should hear the lecture which I am prepared to give." With the students' encouragement, he begins, saying,
"Anatomy is more or less the study of the human body. The human body is not necessarily the human being. Here lies a cadaver. The fact that she was, not long ago, a living, warm, lovely young girl is of little consequence in this classroom. You will not be required to dissect and examine the love that was in her, or the hate. All the hope, despair, memories and desires that motivated every moment of her existence. They ceased to exist when she ceased to exist. Instead, for weeks and months to come, you will dissect, examine and identify her organs, bones, muscles, tissues and so on, one by one. And these you will faithfully record in your notebooks, and when the notebooks are filled, you will know all about this cadaver that the medical profession requires you to know."
Patients are not a disease and they are not a condition; they are human beings and if we are to conduct a medical home, we must see them as more than a patient; we must see them as persons with hopes and fears, loves and hates, beliefs and passions. This is clearly the first principle of patient-centered medical home. It is an effort for a new generation of healthcare providers to capture an old attitude about those whose health needs attention, either because they want to retain it before it is lost, or they want to regain it after it has been lost. It is a frame-of-mind which sees patients personally rather than professionally.
The next medical home portrayal in People Will Talk follows a symphony rehearsal. Praetorius is the conductor of the medical students' symphony and after the evening rehearsal, he returns to his clinic to check on a patient. A science professor, a member of the symphony, has dinner with Praetorius and asked if there was anything interesting at the clinic. Dr. Praetorius declares, "A physician respects the confidentiality of his patients and does not discuss them with anyone." In the medical home, all care givers respect the confidentiality of patient information." One of the foundation stones of trust is confidence that personal information will not become public. That which you are certain will be held in absolute confidence can be shared with another.
Continuing with some generic details of a case, Praetorius speaks of his need to involve the family in the solution to one patient's health problem. This extends beyond science and the idea of "patient" and involves the person as a whole being. Realizing how intimate Dr. Praetorius is becoming in this case, his scientist friend responded, "Has it ever occurred to you that none of this is your business." Praetorius asks, "What is my business?" The scientist declares, "To diagnose the physical ailment of a patient and to cure them." The doctor rejoins, "Wrong; my business is to make sick people well. There is a vast difference between curing an ailment and making sick people well."
This is where "process" - the steps and actions taken in order to "make sick people well" - and "outcomes," which are defined by what "being well" is understood to mean, come together. "Making sick people well," is not defined by avoiding death but by helping people be a whole person - a well person - even while they face death. Repeatedly in the movie portrayal of the life of Dr. Patch Adams, this message is addressed.
Medical Home always involves addressing end-of-life issues, helping persons deal with their own mortality without them seeing death as a failure of life. Death is inevitable; how it is approached determines whether a sick person, who is incurable, can be made well even when dying.
In the second day of the movie's story, a number of medical home concepts are illustrated. As Dr. Praetorius arrives at his clinic, people are outside the clinic building laying in the sun and enjoying the fresh air. Medical home involves normal behavior, even while seeking health care. The first object of medical home is encouraging a patient to maintain wellness. In healthcare, we often place the person, as a patient, in an unhealthy environment. We put them at bed rest rather than keeping them mobile. We limit their food rather than maintaining their nourishment. Often, we them as "being" sick, rather than treating them as healthy people who have an illness. The difference can be the difference between getting well and not.
Realizing that nutrition is central to good health and to "getting well," Dr. Praetorius responses to a nurse who said, "I'd like all the patients to be served breakfast at the same time. I cannot operate the kitchen without more personnel if they are not," saying, "Then hire more people to work in the kitchen." The nurse persists, "But it is common practice in hospitals to serve all the patients at one time." Praetorius declares, "Not in my clinic. No patient will be awakened from a health-giving sleep and forced to eat breakfast at a time which pleases culinary union." The nurse rejoins, "But is it a good economy." Our doctor concludes the discussion by stating, "Bad therapy is never good economy. If you have to economize, do it in the doctors' dining room."
Medical Home puts the patient first and designs processes for meeting the patient's needs and not the staff's. 1951 was a simpler time, but in the 21st Century, it is possible to regain some of that simplicity for the patient's safe. If one patient will eat at 10 rather than at 8 AM; medical home feeds him/her at 10. If another person will eat at anytime, he/she can be fed at the staff's convenience. There are great demands upon the time, energy and attention of nurses. There are great financial pressures on healthcare providers and organizations. But, in the face of these demands and pressures, we can remember that in order to "survive" their hospitalization, the patient should, "eat up," "get up" and "get out." The three elements of successful care in the hospital involve nutrition, activity and transition to home.
While on the subject, Dr. Praetorius turns to another nurse and says, "And I will not have all of the patients bathed at the stroke of a gong for the convenience of the nurses. One of the reasons I started this clinic is the firm convictions that patients are sick people and not inmates." The principle is the same. A bath is a task for a nurse, but to the patient - to the person of their charge - it is an important part of who they are and it has medicinal benefits.
The last scene we will review shows Dr. Praetorius entering a patient ward after the above conversations. He approaches the bed of a very sick patient who is dying, and said:
"I bet I know what you are thinking, here comes Dr. Happiness; the good humor man. He tries to cheer me up and all I want to do is to hit him with an ice bag. Right?" The patient responds, "Wrong." Dr. Praetorius continues, "Not that I blame you. One of the few pleasures of being sick is the right to be miserable. And, don't let any doctor tell you differently."
The patient said, "I was thinking it's not much fun getting old." And the doctor continues, "It's even less fun not getting old." She answers, "I want to die." Dr. Praetorius says, "You'd like that wouldn't you; just to lie around in a coffin all day with nothing to do."
The patient asks, "Doctor, does it hurt when you die?" He answers, "Not a bit. Where did you get that idea?" The patient states, "They tell me there is so much pain." The doctor, asks, "Did anyone who actually died tell you that?" The patient laughed and said, "Of course not."
Dr. Praetorius then tells the patient about a personal experience he had as a child. He was sick and everyone thought he was going to die. He relates that he felt that he was floating on a cloud and looking down at a scene in a play. He said, "Dying was very pleasant, but when I got better, I had a severe headache and vomiting for three days. I never felt as good alive as I did while I was dying." This scene concluded with the dying lady smiling and saying, "You certainly make dying should like a pleasure, Doctor."
A complete review of this movie - its good and bad - would take a volume, but it does gives us a "feel" for what medical home is. In some ways it is impractical and in others it is imperative. I do know that I would love for every medical student to see this movie and Patch Adams and The Doctor and Keys to the Kingdom. The message of each of these films helps us empathize with others, who are sick. Each portrayal has weaknesses. In the case of People Will Talk, I think Dr. Praetorius portrays an inappropriately negative attitude toward nurses, but his ideas are instructive for us. I think it will take a life time to understand and to create a true Medical Home, but this is a start and the journey is worthwhile.