You Are Not Your Chief Complaint (Part 1)

Michael, a 48 year warehouse manager, had been experiencing intermittent episodes of low back pain since a lacrosse injury in high school.? For many years the episodes were short lived – lasting a few days and responding to ibuprofen and avoidance of lifting.? In recent years he had been bothered more frequently especially if lifting more at work. Michael also struggles with depression. No longer as active, he eats poorly, smokes, has gained significant weight, and is pre-diabetic.

I have been thinking about people like Michael (of which there are many millions) for years. It wasn't until recently that the true problem came into focus and set PeerWell on a mission to change the status quo.

When patients seek care for themselves or their loved ones, they start with a symptom or primary concern. For non-clinical people (like myself) this is called the chief complaint.

Normally Michael’s experience would begin with him focusing on his chief complaint, such as lower back pain. He’d then look for a doctor specifically for his back pain since it is what he believes is most impacting his daily activities. It is not obvious to Michael that his depression, weight, and pre-diabetes could be contributing to his back pain; he may not even be aware he’s struggling with those other issues.?

Where should Michael go to seek care?

• If Michael went to his primary care doctor (PCP) - assuming he has one - that person probably has 10 minutes for a visit. They would likely immediately recommend a spine surgeon follow-up visit or physical therapy (rarely). He probably leaves it to Michael to find the right Orthopedist or Physical Therapist that works with his insurance.
• If Michael went to physical therapy, he may get a few exercises to do but is unlikely to get checked out for depression (especially if Michael isn’t raising that issue as his chief complaint).
• If Michael went to a neurosurgeon, they might order up an MRI and find something that could be causing his back pain (even though most often the MRI results are benign abnormalities). ?This usually results in a recommendation for spine surgery that may provide no benefit.

54% of people recommended for spine surgery by home providers did not need spine surgery.

In most cases, Michael would not get treated for all the issues contributing to his back pain.

Care Navigation

A Primary Care Physician, an Orthopedist, or Physical Therapist are possible doors behind which Michael can get treated, but which one is the right door?

There is a lot of discussion today about the “new front door” for healthcare and there is a recognition that we need to change the way people access care. Care navigation services offered via companies like Accolade or Grand Rounds might be the right answer for people like Michael. A navigator could guide him through the most appropriate door. But, I believe Michael is still not getting the full care that he needs.?

We don’t just need a new front door. We need a new approach to care altogether. We call it “Whole Person Care.”

It’s not enough for a care navigator to point people to the right doors to walk through. To be sure, this is a step better than leaving the burden to Michael who is ill-equipped to find the right door for himself. The education hurdle is just too high.

However, regardless of which door he walks through, he is still only receiving a fraction of the care he needs. This is because of the underlying architecture of the care delivery system that has built up over the last century.

Care Delivery in the Industrial Age

So why did we design a health care system in such a way? A series of baton passes from one specialist to another.

Today’s healthcare delivery models were built up during the Industrial Age, post-World War II. Delivery systems leaned heavily on the principles of division of labor way back from Adam Smith and the Wealth of Nations. And also from mass scale production philosophies like Ford Motors assembly lines which also followed similar rules. I’m grossly oversimplifying here but the central thesis is to divide functions into specialized parts and rely on a centralized coordinating function to get things working from input to output. It’s not dissimilar to the mechanism behind how we manufacture a car.?

We see this in healthcare today where there are hundreds of medical specialties and subspecialties. And there are large hospitals that are meant to provide the “centralization coordinating function”. Another view could be that the large insurance carriers are the centralized coordinators by aggregating specialists into a network available for the patients to choose from and using utilization management services to facilitate care delivery (this is the most charitable explanation I could come up with). There are other groups that are positioning themselves as aggregators or centralizing coordination resources, like benefits aggregators, care navigation tools & services, digital health platforms, etc.?

The presumption is that there is a specialist for exactly the issue that is the patient’s chief complaint. The patient can go straight to that “door” and get what they need to resolve their issue.

Diseases of Behavior Behave Differently

However, this is faulty logic since it assumes diseases follow the same principles of division of labor and that each disease is an independent actor. That is not how diseases function, especially diseases that are rooted in behavior and environment like back pain. They interact with each other and cause symptoms that might present in other ways than the diagnosis might indicate and at different times.

In Michael’s case above, he needs treatment for his back, mental health, weight, diabetes, and more. In the current model, where we match each disease to the most appropriate specialist, it leads to many specialists with multiple treatment plans, often in conflict with each other. Moreover, Michael is run ragged trying to meet with all the different specialists and even his primary care doctor or care navigator would be overwhelmed trying to guide all of this care properly.

What’s neglected is how back pain is exacerbated by his weight, how his weight is a result of his depression, and so on. It is a gordian knot of interactions that no one specialist will be able to untangle. And no specialist is set up to coordinate with all the other specialists and adjust their care plans and recommendations as a group.

While specialization has helped us scale, it has now become an obstacle that is growing more costly each day and not helping people overcome their health challenges.

What's Next? Care Delivery for the Information Age

The push towards specialization is natural and still necessary. It does help for providers to specialize as they develop expertise through experience & repetition. The challenge is in the interaction between the providers. Pre-information era, coordination between providers was inefficient to say the least. Sharing information and collaborating with other providers would take too much time and so it made sense to compartmentalize and focus.?

However, post-Internet the constraint is no longer there. Providers and patients with the right tools can coordinate seamlessly, share information, adjust treatment plans all in real-time. The past 18 months has proven that we can operate healthcare using collaboration tools like Zoom, Slack, and more.

This enables “Whole Person Care” - fully integrated multi-specialty practices that can address the full set of patients health issues like Michael’s above. Specialists are necessary to diagnose and treat specific conditions, but those specialists can dynamically adjust care plans based on direct collaboration with other specialists on the care team. Because information is readily available and providers can speak to each other via productivity tools built up over the last decade, this has only become possible in the last couple years.

This is a completely new model of care and a new era for care delivery. It is distributed and federated at its core. And it will lead to better, sustained outcomes for patients and at significantly reduced costs. Since providers will be working closely together, it will eliminate unnecessary or redundant procedures, labs, prescriptions, and more. Patients will not have to waste time coordinating visits (and travel) to different providers and go through redundant history and physical intakes.

In the next article, I’ll dive deeper into what is involved when building modern, tech-enabled multi-specialty practice.