Friday, October 21, 2011

Hospice and The Way Of The Master Diagnostician

I had the privilege of giving the keynote address for the Amedysis Hospice Strategy Summit last week in Louisville, Kentucky. Below find an abridged version of my comments.

Hospice and The Way Of The Master Diagnostician

We are facing a crisis in our healthcare system. If you listen to the politicians, two forces are growing that are diametrically opposed. On one side, the right composed mostly of Republicans. On the other, the liberal left and Democrats.

Although they never seem to agree, if you listen closely, we are all searching for the same thing. Our arguments, when distilled to their basic tenets, are similar.

We have to define the most salient indicators of quality and learn how to motivate our practitioners to adhere to them.

Quality and motivation. It sounds simple. But in reality it is anything but.


Defining quality, in our current healthcare system, is often a struggle. If you ask my colleagues what makes a "good doctor", we will likely mumble something about excellent care. But if you push us further, you'll mostly get blank stares.

Our progress, to date, in aspiring towards quality has been limited to measurement of indicators. We ask ourselves over and over again. What are the indicators of optimal care.

Anyone who understands Goodhart's law, however, knows that we are probably off base. Goodhart's law is an economic principal that simply states:

When an indicator becomes a target, it loses its quality as a measure.

A fun example is Soviet Russia. The government tried to incentivize nail factories to create more product by paying personel according to the number of nails produced. The employees ingeniously increased production by thousands a day by making small ineffective nails.

A more sobering example is the four hour pneumonia rule. Researchers found that patients hospitalized with pneumonia who received antibiotics within four hours of admission to the emergency room fared better. But when they incentivized EDs to give antibiotic faster, their were disastrous results. Over use of medications in inappropriate patients caused worse outcomes and higher costs.

This is Goodhart's law.


So even if we could identify the indicators of quality health care, how would we motivate our practitioners to follow them?

The government espouses pay for performance and the carrot and stick method. But one wonders if this flies in the face of motivational theory.

Self determination theory says that we shouldn't try to externally motivate behaviors that should be internally motivated. It never works.

Picture growing up in a crowded neighborhood. The kids on the block run roughshod on all the beautiful lawns. One day the smart guy on the corner lot says to the children:

Please....I'll pay you ten dollars a day. Come play on my lawn.

A week later he returns and scolds the children for doing a poor job and decreases their "wages" to five dollars a day. Another week later he returns and tells them he no longer will pay. When he asks them to play on his lawn they smirk. And they never step foot on his grass again!

This story may sound far fetched until you realize that the UK has been using pay for performance since 2000. A study in the British Medical Journal recently found that the carrot and stick method had no effect whatsoever on blood pressure control or hypertension related morbidity and mortality.

It appears that for people to become internally motivated to perform a complicated task, they need to feel autonomous, competent, and connected. Although it sounds hard to believe, having a central authority dictate your actions can have negative effects on such feelings.


I have come here today to tell you that we don't know how to measure quality, and even if we did, we are poor at motivating such behavior.

So we might as well give up, right?

Well, I have an idea that there is a better way. It's the way of the master diagnostician.

Our current healthcare model is a biological one. We focus on genes and diseases, symptoms and treatments. The problem is although we are 99.9% similar genetically, each one of us is very different. We react to stress differently. We get sick differently. And we respond to treatment differently.

The master diagnostician not only recognizes the biologic aspects of health, but also understands biologic variability, the psychological, social, and spiritual components of well being. In other words, the master diagnostician excels at giving each individual patient exactly what they need.

Take, for instance, two patients with coronary chest pain. One is fifty five years and otherwise healthy. The other is ninety five and has end stage cancer.

My fifty five year old will get maximal aggressive hospital care. My ninety five year old will get nitro, morphine, and be told to take it easy at home. Both patients will get appropriate care.

There are no quality indicators or carrots and sticks that can easily accomadate both of the above scenarios.


The master diagnostician learns to focus on what each patient needs and not necessarily what they want. The thirty year old with constipation does not need a cat scan of the abdomen. He might want it. He might believe that it will be the only way to calm the fear in his heart. But the risks and likelihood of incidentalomas is too great.

The master diagnostician also realizes that medical care has to respect each individuals right to make decisions. Although everyone should get a screening colonoscopy at age fifty, some patients just don't want one. And that's OK as long as full disclosure of risks and benefits has occurred.

The theory is simple. Give people all that medicine has to offer, but also search each patient for what they really need. Patient centered care that is tailored to each individual's circumstances.


I believe if we go the way of the master diagnostician we will achieve the penultimate heathcare reform trifecta. We will increase survival, decrease costs, and improve quality.

I not only believe this, I know it.

How do I know it? Because their are master diagnosticians among us who practice truly patient centered care. They are one of a kind, and their numbers are growing.

They are hospice and palliative medicine practitioners.

Hospice medicine is the only field that has resisted getting stuck on biologic necessity, and has learned to evaluate the psychological, social, and spiritual components of health.

To the hospice and palliative medicine team your cancer is only one concern. They also want to control your pain, prepare your family, and even make sure your dog is taken care of after you die. And why do they focus on such inane things....because that's what the patient tells them to. They look to help each and every soul receive exactly what they need.


Earlier I boasted that the master diagnostician theory would bring about the healthcare reform trifecta. That longer survival, lower costs, and increased quality of life are achievable.

I you look at recent data, hospice and palliative medicine have conquered all three goals.

Data from a New England Journal of Medicine article from 2010 showed that patients with metastatic lung cancer lived three months longer if given a palliative care consultation at the time of diagnosis. Data out of Duke in 2007 showed that being on hospice saved medicare roughly $2903 per patient. And finally, too many studies to count have shown that people who die in hospice suffer less pain, are more likely to have their needs met, and their families reported calmer deaths.


For all these reasons, I believe we are entering the golden age of hospice. These master diagnosticians are standing as shining examples of what we need to achieve to usher in the age of true healthcare reform.

In order for the movement to continue, two obstacles need to be overcome. First we need to rebrand the movement. The term "hospice" is too old and misunderstood. It no longer serves.

Second, hospice and palliative medicine need to become an earlier part of the health care continuum. Too often, they are relegated to "end of life care". The true power lies in early intervention.

Thank you for listening


Maggie said...

Nice speech!

The only thing I would add, as a longtime hospice volunteer, is that sometimes the person who declines aggressive treatment actually gets better without it.

We often find that the person living alone whose illness appears 'terminal' may recover both function and quality of life in an atmosphere of supportive care for pain, isolation, and fear.

Many of our volunteers go right on visiting such patients after the patient has 'graduated' from hospice and gone back into the general population of people whose death date is not predicted. Sometimes that can make all the difference.

The master diagnostician is at work in those cases, too.

tracy said...

We had amazing Hospice workers last Summer while my Dad was dying. i can never thank them enough. They took care of ALL of us.

Thank you for all you do, Maggie!

Thank you, Dr. Jordan