Session 3

This section contains all of the suggested discussion questions for class meetings.

SESSION 3:

• (5') Welcome Back

  • Students share any updates for the class; any comments lingering from the last session

• Optional (10') Discussion on Narrative Medicine readings

  • Narrative and Medicine was provided to give you an idea of what “narrative medicine” really means. In essence, it’s a term coined by Dr. Rita Charon that encompasses the process of attentive listening and reflecting for doctors.

    • Have you tried reflecting through writing during your clinical training? Or have you been instructed to do so? How has that helped you, or not? Do you agree that illness reveals itself in “stories?”

    • We’ve discussed that an important component to delivering high value care is identifying and treating towards the outcomes that matter to patients. How do the goals of Narrative Medicine as identified by Dr. Rita Charon coincide with those of HVC?

  • In The Art of Medicine, Dr. Charon discusses how, with difficulty, medicine traverses multiple spheres: the known/unknown, the universal and the particular, the body and the self; and that through taking a narrative approach (i.e., via narrative medicine), clinicians can begin to resolve these tensions. Illness, as she says, reveals itself through stories; yet evidence-based medicine has been touted as a preferred approach to delivering medical care. She challenges the claim that EBM and narrative medicine clash and instead has developed a program -- evidence-based narrative medicine -- that teaches students the value of evidence found in a multitude of texts.

    • “EBM has earned the reputation of dismissing the importance of the singular predicament of the patient and the individual judgment of the doctor.” Do you agree that if we practice EBM we necessarily negate the individualistic needs and desires of our patients?

    • What are your thoughts on the “clash” between evidence-based medicine and “the narrative singularity of both patients’ and clinicians’ lived experience?” (Charon 2008). Do you agree with Dr. Charon that there are ways to reconcile the “differences” between these two approaches?

  • The article Narrative Medicine and Healthcare Reform asks the crucial question: “what kind of healthcare do we want?” Writing in October 2010, five months before the passage of the ACA, Bradley discusses how narrative medicine, as complicated as it is to define, may be able to help us build a better healthcare system. Bradley argues that the U.S. medical education system developed to prioritize “objective,” (i.e., medical facts) over the “subjective” (raw human experience.)

    • Do you think that medicine as it stands today has lost its human aspect?

    • Do you believe your medical education thus far has balanced the objective with the subjective?

    • How do you see the value movement as panacea for modern medicine’s failures?

    • What are ways we can bridge the health system’s goal of identifying and tracking PROMS with that of the physicians -- to address patient goals on an individual, case-by-case basis?

• (20') Discussion on Overkill

  • • In Overkill, Dr. Gawande explores the concept of “low-value care,” drawing upon both his own experience as a surgeon and that of stories relayed to him by patients. Through this exploration he makes visceral the problems that come from overtesting, overdiagnosis, and overtreatment. He also defines the “virtuous patient,” as a necessary player in the healthcare system. This is someone who does their research and makes informed choices before embarking down a particular care plan.

    • What are your thoughts on the adage “he’s a surgeon so he’ll recommend surgery”? As a future doctor, how do you think you can balance focusing on your specialization without neglecting the value of other specialities?

    • Discuss the pros/cons of testing when there are no symptoms. How can we relate this to the COVID19 crisis?

    • Thinking about the concept of time in medical visits -- how does more time with patients cut down on medical costs?

• (20') Discussion on What the Healthcare Debate Still Gets Wrong:

  • In a review of Uwe Reinhardt’s book, Priced Out, this author criticizes Dr. Gawande’s arguments brought up in an earlier article he wrote (which he referenced and followed up on in Overkill) where he implies that to change the excessive waste generated in our healthcare system (due to “needy” patients (i.e., over utilizers) and “procedure-happy providers”), we can “keep the market intact” and just “realign market incentives.” In contrast, Reinhardt argues that actually, it’s not how much healthcare we are using but how much our healthcare costs thanks to price gouging by insurers.

    • Whose argument do you buy -- Gawande’s or Reinhardt’s?

    • Do we need more robust evaluations of models like ACOs in order to support a transition to them? Or, is Reinhardt right - it doesn’t matter how you slice it and change our healthcare model: if we don’t fix the financing, we won’t fix healthcare?

• (5') Discussion on The Strategy that will Fix Healthcare

  • This article lays out Porter and Lee’s thesis - to create a value-based healthcare system, we must first define the goal, and the goal needs to be prioritizing patient outcomes. Their approach includes: creating IPUs, measuring outcomes and costs for every patient, moving to bundled payments for care cycles, integrating care delivery systems (note: as of 2013 when the article was published, “most multi-site organizations are not delivery systems, at least thus far, but loose confederations of largely stand-alone units that often duplicate services”), expanding geographic reach, supporting a comprehensive IT platform.

    • Porter’s article talks again about measuring outcomes that matter to patients. What are some examples that he lists versus the outcomes that doctors might be used to measuring?

      • There are three Tiers to outcomes: Tier 1 involves the health status achieved (i.e., functional status); Tier 2 relates to the nature of care cycle and recovery; Tier 3 relates to health sustainability (i.e., how long does that new hip last?)

** BREAK **

• (1 hr) Discussion on Module 4 & Mini-Presentation: IPUs/PCMHs **

• **Course facilitators should send the IPU/PCMH questions ahead of time to Mini-Prezzers

  • This module discusses incremental and systemic changes that can be made to reduce problems associated with healthcare and details two healthcare delivery models that aim to address the problems associated with uncoordinated care and fragmentation.

    • What are some challenges that a PCP faces to coordinate patient care? Do you think the responsibility should be the PCPs?

  • What is the fundamental difference with integrated practice units (IPUs) when compared to the way most healthcare is delivered in the U.S.?

    • In IPUs, care is organized around the needs of the patient, rather than by the expertise/specialty of a given health professional.

  • Would you want to work in an integrated practice unit? Why or why not?

    • Ensure the group highlights the benefits of IPUs for physicians and other health professionals; for example, better health outcomes, lower costs and more efficient cost accounting, better ability to have input and coordination across cycle of care, shared decision-making process between all providers and their patient, lowers burden of trying to coordinate with disjointed, non-co-located providers and susceptibility to malpractice risk.

  • Would you want to obtain care at an IPU? Why or why not?

    • Well-organized and high-functioning IPUs provide patients with more efficient, patient-centered and organized care that is less susceptible to repeat testing, uncoordinated care, risks associated with lack of communication, higher costs of care, poorer outcomes, and higher focus on measuring and obtaining patient-prioritized outcomes.

  • PCMH reps discuss pros/cons of PCMHs. What do recent data suggest about PCMH efficacy?

  • While patient-centered medical homes and IPUs have similar fundamentals and components, how are they different?

    • As stated in the module, “PCMHs and IPUs grew from different gardens but ultimately seem to have converged on the same underlying principles. While PCMHs provide longitudinal care over a patient’s lifetime and generally regardless of his/her condition, IPUs tend to concentrate on conditions for which the care cycle is well-defined. IPUs treat patients with specific circumstances or conditions, including specialty care. IPUs are generally co-located, multidisciplinary teams of clinical and nonclinical providers (e.g., case managers, social workers, activity coaches) who treat circumstances or conditions over a full care cycle. Whereas PCMHs are for generalized care of all patients, IPUs develop solutions for patients who share a condition or set of circumstances (e.g., MSK pain, frailty, or breast cancer).” It is possible to think about settings where PCMHs and IPUs could work together (for example, a patient is cared for at a PCMH but when he develops knee pain is referred to an MSK IPU which communicates with his PCMH and the patient returns to the care of PCMH following full management of his knee pain. Another example could be a patient in a PCMH who is diagnosed with cancer and then is referred to a cancer-based IPU for primary oncology care and management.)

    • As support for PCMHs, the ‘American Medical Home Runs’ article notes how four examples of primary care sites in the US reduced costs by 15-20% without sacrificing quality of care.

  • Optional: Discuss some of the findings from the JAMA article (Association of High-Cost Health Care Utilization With Longitudinal Changes in Patient-Centered Medical Home Implementation) on the challenges regarding PCMHs, which measured longitudinally the effects of PCMHs on reducing healthcare expenditures.

    • What challenges are there in creating team-based, rather than individually-run practices and clinics?

      • Potential discussion starters: the way providers are currently reimbursed, lack of processes or appropriate use of HIT, fragmentation between clinics

  • (5’) Wrap-Up