Medical Futures Lab

This semester, as we’ve investigated strategies to improve inter-professional communication and care coordination in intensive care unit (ICU) rounds, I’ve been surprised by two things:

1. Everyone’s seen the problem. This isn’t a situation where astute perception revealed systemic undercurrents; anyone who’s participated in rounds is intimately familiar with its inefficiencies. Everyone understands this, but nobody has definitively addressed it.
   
2. Everyone’s thought about solutions. Whenever we’ve discussed rounds with a patient or provider, it’s profound how much they’ve given this thought. Anyone can readily suggest areas for impact, or even specific methods for improvement. Why hasn’t intuition translated to innovation?

It’s attention – or more specifically, the scarcity of it. Nobody recognizes the opportunities for creative destruction in healthcare better than the people who spend each day in the trenches of clinical medicine. But after patient care, administrative hurdles, research responsibilities, teaching duties, continuing education, and something that might resemble a personal life, providers have neither the interest nor the capacity to cultivate an innovative spirit.

Which leads me to ask: what might healthcare look like if we gave providers the time and space for disruptive thinking?

What if medical teams borrowed from Dropbox’s Hack Week? What if health institutions, as Google did, allowed every provider 20% of their time for creative ventures? What might the likes of the inventive energies and constructive cultures that created GMail, AdSense, and Google News do for healthcare? A different approach to ICU rounds? A re-designed EMR interface? A stronger capacity to screen for, and address, the social determinants of poor health? The opportunities are limitless.

And thus, for healthcare providers, students, patients, entrepreneurs, everyone, I offer these thoughts:

1. What would you do if 20% of your professional time was protected for creativity and inspiration?
2. In what ways does your work atmosphere cultivate innovative vision, and how could it better meet that goal?
3. Beyond limits to time and attention, what are other functional obstacles to innovation in health settings, and how can we mitigate them?

When I was first diagnosed with Hodgkin’s Lymphoma, my oncologist sat down with me to discuss treatment options.

There were two options for standard of care, she told me. I could get six cycles of chemotherapy, or four cycles of chemotherapy followed by radiation. I could also enroll in a late-phase clinical trial, which was testing the long-term results of rituximab biotherapy on Hodgkin’s patients with cancer cells that fit a certain profile.

Rituximab had already been approved for other lymphomas, and a published study showed improved results when this biotherapy was combined with chemotherapy. It also was fairly risk-free. Although various adverse effects do occur with rituximab, the most common is an allergic reaction, which they give Benadryl for during treatment.

I decided not go on this clinical trial because of concerns about the control group. However, rituximab intrigued me. I found the previous studies convincing, even though the prices for the drug were astronomical – more than $6,000 per dose, and I would need more than one dose. So I called up my insurance company, and they agreed to review my case.

They ended up paying for my treatment with rituximab, which makes good business sense. If I don’t relapse, my insurance doesn’t have to pay for the hassle. However, this is the key point: I would have never known about a vital drug if my oncologist had not mentioned a clinical trial. 

What else can we learn from my anecdote?

• Conversations about clinical trials indicate a high quality of care. My oncologist gave me several options, one of which represented the cutting edge of cancer research.
• Patient education and engagement matters. I had to be my own advocate to the insurance company, and it was precisely because I was educated and pushed that I was able to get the best treatment possible.

A lot of the discussion that we have in class is based around e-patients. In fact, one of the groups even has the direct problem of figuring out how to create more e-patients. So I find that I spend a lot of time thinking about this subject.

During this process, I seem to have come to the conclusion that a majority of the work surrounding e-patients has been directed at the patient end of the doctor patient spectrum. That makes sense right? We want “engaged” patients so we focus on giving these patients the access they need to knowledge and resources to understand and improve their health. So when we look to “create” more e-patients we focus on the patients. Sounds reasonable.

But we’ve become so focused on the patient that I can’t help feeling like there is a strategy we’re overlooking.

The picture below is of a model of patient-doctor communication that we looked at in class. When we look at creating e-patients we think of starting at the purple arrow: where engaged patients engage their doctors who then reciprocate.

But what if we started at the orange arrow?

I think there is probably a large proportion of patients that are very accustomed to the traditional model of patient-doctor communication. Why don’t we use that to our advantage? If doctors used their influence to encourage patients to start doing some of the activities associated with e-patients and gave them the resources, patients may be more motivated and feel more comfortable becoming e-patients.

 All doctors have to do is get a patient started; once that happens, I think the nature of the e-patient community will automatically encourage a patient to take more responsibility for their health.

That’s why think there needs to be a segment of the e-patient movement that is focused primarily on convincing doctors to encourage their patients; a group focused on teaching doctors the value of e-patients.

Maybe that already exists. Or maybe I’m wrong. Maybe this is too controversial. I know e-patients sometimes pride themselves of being autonomous and not needing a doctor to tell them what to do.

But if this can help us create more e-patients, isn’t that a goal we all share? It’s definitely something worth thinking about.