Provider (prə-vī’dər) n.
1. One who supplies a means of subsistence.
2. One that makes something, such as a service, available.
This is part 2 of a 4 part interview series (see previous here) in anticipation of the upcoming Health 2.0 Conference. This second interview is with David S. Sobel, MD, MPH physician extraordinaire from Kaiser
David S. Sobel, M.D., M.P.H., is Medical Director of Patient Education and Health Promotion for The Permanente Medical Group and Kaiser Permanente Northern California which serves over 3.3 million members. He has practiced adult primary care medicine for over 30 years and was the physician lead for the national initiative in Patient-Centered Care for the Care Management Institute of Kaiser Permanente. He is coauthor of seven books including Living a Healthy Life with Chronic Conditions, The Healing Brain, Healthy Pleasures, and The Healthy Mind, Healthy Body Handbook. He is also a recipient of the national Healthtrac Foundation Health Education Award.
The true “Primary Care Provider” is the patient – we need to do everything we can to support a true partnership model of health care.
What do you actually do on a daily basis at Kaiser?
My work is a stew. Chunks of clinical practice (some patients I have worked in partnership with for over 25 years), generous helpings of health education program development and evaluation, and a sprinkle of lecturing and teaching. It has been a very satisfying feast.
What are your core areas of professional interest?
I believe my work can be looked at in three ways:
- Patient are not consumers of health care – they primary care providers. Patients are most often viewed as consumers of health care, and health professionals are seen as the primary health care providers. In fact, 70-90% of all symptoms are self-diagnosed and self-treated without the help of health professionals. The true primary care providers are people themselves. For example, recent evidence shows that trained lay leaders conducting groups of patients with mixed chronic illnesses can measurably improve health behaviors, enhance health status, and decrease hospitalization. A vital function of the health care system then becomes increasing self-care competence and empowering patients to become active partners in health care. We are doing everything we can to empower our patients to become partners in their care as they are the ones who understand living with their condition better than anyone. Kaiser Permanente has been working on this partnership since its inception and I remain a huge advocate of this perspective which fundamentally reshapes the patient-physician relationship.
- Brain/Body/Medicine – The integrated patient. I have also spent a fair amount of time evaluating how the Brain and the Body interact with one another. I often use the phrase, “The Brain Minds the Body” to help people realize this key bilateral relationship. Patients are also often treated as mindless machines to be fixed by medical care. In truth, the human brain is an internal health maintenance organization. Our thoughts, feelings, and moods can have a dramatic impact on the onset of some diseases, the course of many, and the management of nearly all. Nearly a third of patients visiting a doctor develop bodily symptoms as an expression of psychological distress. Another third have medical conditions that result from behavioral choices. And even in the remaining patients with medical disease, the course of their illness is often strongly influenced by their mood, coping skills, and social support. In disease management and prevention much emphasis is placed on changing patients’ behaviors. Yet, emerging evidence suggests that attitudes, beliefs, and moods may have as great an impact on health status as health behaviors. Health status can be enhanced by strengthening patients’ self-efficacy and confidence in living a healthier life with chronic conditions. We needn’t terrorize our patients with failure experiences, but rather build them up mentally and emotionally in order to experience successful outcomes.
- Healthy (Not Guilty!) Pleasures. Building on the attitudinal/mood studies previously mentioned, I set off to evaluate whether feeling good is actually good for you. We found that people who actual enjoy life – who fully participate in optimistic, sensual, and altruistic pleasures have better outcomes. Many people think that to promote health they have to undertake strict weight loss diets, adopt punishing exercise programs, avoid salt, shun cholesterol, and follow all sorts of arduous, pleasure-denying regimens. Fortunately, scientific evidence now suggests that for most people doing what is pleasurable actually pays off in both immediate enjoyment and better health. The healthiest, most robust people seem to indulge in many small daily pleasures and cultivate a positive, optimistic view of their lives.
How did you get involved Health 2.0?
I first met both Matthew and Indu at the Information Therapy conference in the fall. As I began to learn about some of the initiatives within the Health 2.0 community, I had to smile because many of these things we already do within the vertically integrated Kaiser system (of note, Dr. Sobel’s definition of “vertical integration” takes the connectivity all the way down to the patient as the primary care provider). In fact, our Epic implementation (KP HealthConnect) has tremendous functionality for the individual patients, of which I was pleasantly surprised (I reminded him that you can buy a lot of cool stuff for $4B [yes, that is a B]).
What do you see as the promise of the Health 2.0 movement?
I see the real potential here in using the web to make healthy connections between all the people in the care process: patient to patient, and patient to and from clinicians, Again, this is where something as simple as the Epic Shared Record allows physicians, patients, and other care providers to collaborate around the patient’s record. As opposed to a stale and sterile website that pushes information to you, we now have an interactive medium of information exchange that improves health care delivery.
How do you define Health Care 2.0?
I am very cautious and reticent to provide a strict definition which might not only box in my thinking, but the potential of the movement to expand in unintended and unanticipated ways. William James, American psychology around the turn of the 20th century once said, “We have to avoid premature closure with reality”. Too many boxes and assumptions regarding evolving concepts can create artificial screening mechanisms which change our perceptions. I am much more comfortable with fluidity as opposed to rigidity in the creative process.
Fair enough. How do you then “describe” the collective Health 2.0 phenomenon?
I see it in the multiple facets of how a patient can become a better partner with the health care system in the way that the share their knowledge, experience, and personal information with each other. Much of what I see within the Health 2.0 universe are technologies, innovations, and organizations that are attempting to empower the patient as a primary care giver. Enabling sharing in this way is constructing, enabling, and infinitely better way to partner with the professional care givers. Health 2.0 is creating the social construct, organizational structures, and enabling technology to achieve this objective.
Primary Care has been noted by many to be in rapid decline – how do you see this impacting your efforts as a primary care provider?
While Kaiser Permanente is clearly not perfect, we have done a phenomenal job of aligning incentives and thus creating an environment where a patient physician relationship can thrive (no pun intended on the well known Kaiser campaign). As physicians we are rewarded to keep our patient panels “healthy, happy and at home”. If we fail in any of these three key areas, everything we do falls down.
Do you think the recent momentum behind the Medical Home concept can restore primary care to its appropriate place within the house of medicine?
I have a hard time with this “new concept” called the Medical Home as this is how Kaiser has practiced medicine from Day 1. There is far too much magical thinking about the Medical Home and that fact is that you can’t just fix this relationship when all the financial and other incentives don’t align to support the delivery of care via a Medical Home.
We currently manage more than 3.3 million members. We don’t view them as consumers, but as primary care providers. That orientation really changes the way we interact with our patients, and the tools we are developing to foster this concept. We want our patients to have access to their health records, to be involved in a shared medical decision making process, too coordinate their care, and to have them actively participate in their own outcomes. Within the Kaiser system, the medical home is built into the incentive model up and down and is a complete non-issue for us.
Do you see innovations like retail clinics or the episode of care model gaining further traction?
To be honest, I really haven’t paid attention. Again, these trivial band aid reform approaches are a complete non-issue within the realm that I practice (which is liberating by the way!). When we stopped defining primary care teams as Family, General, Nurse practitioners – and included the patient – we really broke through the glass ceiling of the patient partnership model. Because we view them as fellow providers of care, we now begin to seek their advice, ask them to collaborate with us and with each other, and instead of isolate their opinions help them aggregate them instead. They are sharing their expertise with each and with us. This type of collaboration is really what I see as the engine behind the Health 2.0 movement.
Since the “Vertically Integrated” delivery system appears to deliver the best outcomes, what will it take to get the remaining 80% of health care to organize in this way?
That is a tough one because of all the elements that need to conspire to have enough friction, enough heat, and enough problems that we can breakthrough. I fear that it is going to continue to get worse, uglier, and more painful before we hit those transitional breakthroughs on our way to next generation health care.
Some concrete things that will need to happen to get to a new care delivery model:
- Looking at the evidence
- Political Courage
- More very unhappy patients demanding change
- More very burned out providers demanding change
- Employers demanding change
- Alot more pain from other players before the right solution becomes palatable
However, there is a sea change within the attitude of providers toward the Kaiser model. (I relayed my own decision of why I personally chose not to practice at a Kaiser facility due to the perception of the organization and its physicians). You know – that is exactly right – and we have absolutely overcome that professional perception in recent years. There is unbelievable organization pride and a culture of excellence in the care that we delivery. It is not just being proud to be a part of it, but to be a part of delivering objective, measurable, and demonstratively higher quality of are. We see this in our recruiting. Where we used to get a lot of physicians who were just tired of the hassle factor joining KP, now we are getting the best and the brightest who want to practice in an environment of excellence. We typically have scores applicants for every open position. Now, clearly, among our 6,000 providers not every interaction meets our bar, but we are able to measure, manage, and monitor in a way that both supports, encourages, and helps physicians who are seeking excellence. Its been great to be a part of this cultural and professional shift.
Since achieving wider adoption of vertically integrated systems appears to be challenging, do you see a role for “Virtually Integrated” technology/software to coordinate care in this fashion?
I coordinate care delivery with physicians I have never met nor seen before all the time. Technology can and will have a dramatic impact in this area for sure – it can get you pretty far – but again, without fundamental change in the incentives I believe it is just not going to be enough. Quick example, when I just started practicing medicine I did not handle a patient with a red eye (the “red eye” can be a diagnostic dilemma because of an extensive differential diagnosis that ranges from minor to major severity) as well as I could have. The specialist took the time to call me up and in an appropriate and encouraging way provide some input on how I could manage this better in the future. I actually thanked him for his guidance when he remarked, “You know, in a tradition practice setting as the specialist accepting referrals I would have never called you because I know that providing any input would mean that you would never send me another patient referral. However, within the KP system, I want to spend the time to coordinate better care with you because it will save both of us time, money, and provide better outcomes for the patients that we will have a relationship with for a very long time.” I did not appreciate how right he was until I really got more involved with the leadership and management side of medicine. It is appropriate bi-directional accountability that happens in an environment of trusted relationships over time.
What do you want to get out of next week?
I want to absorb some new, “knock your socks off” innovations rather than “knock offs.” I also welcome the opportunity to share some of the experiences and successes we have had in empowering patients as partners in care and true primary care providers.