The Great Healthcare Chasm

chasm

My Story:

During my third pregnancy, I had to move to a different state when I was 32 weeks along.  I showed up at my first appointment with my new midwife group, empowered and knowledgeable, with reasonable questions and a clear sense of how I wanted to approach the rest of my maternity care. 

The particular midwife that I saw absolutely did not like me approaching her with a sense of being a partner in my care.  She clearly felt threatened.  She told me that in their practice, they are used to low income, poorly educated patients and that I would be atypical.  “Our patients don’t usually have strong ideas about how things should go.”  She then informed me that she would be putting a note on my chart to “warn the other midwives” that I would be a “challenge.” 

I couldn’t believe it.  I had done everything right.  I ate well, exercised, delivered two other babies without intervention, and this woman had known me for five minutes and had already written me off as a difficult patient.  She had no sense of who I was or made any effort to approach my care holistically and understand me and why I would these ideas and expectations for my plan.  She was almost incapable of deviating from the cookie cutter approach to patients and individualizing her interaction with an informed, experienced patient.  So we left at odds.  She was mad that I would challenge the status quo and I felt misunderstood and disrespected.

This situation made me ponder for many weeks after; forget ObamaCare, insurance problems and litigation… what is really wrong with healthcare?

There are few topics that stir up as much passion and debate these days.  And for good reason.  Its vital to our quality of life, it represents almost a fifth of our economy and, wherever you stand on its politics, we can all agree that our system has major problems.

The way we do healthcare is broken, despite all of our scientific advances.

Every day, I am struck by how hard those of us who work in healthcare are trying.  Hundreds of new initiatives, better technology, mandatory training.  We have to comply with countless regulatory bodies, track every mistake in order to improve, and work 24 hours a day delivering the best care we can.  But there is a disconnect with our outcomes.  It’s estimated that more than 80 percent of the adult industrial population have a chronic illness. 8 out of 10 adults!?  In three years, it is predicted that it will cost 12 BILLION dollars a day to deal with chronic diseases.

We are working harder, but losing patient trust.  Spending more than ever, but people are sicker.

Why? There are many reasons, but chief in my mind is that there is a great healthcare chasm: the communication between patients and providers. There is an “us versus them” mentality.  Providers feel it towards patients and patients feel it towards providers, they are not on the same team (like me and the midwife in the scenario I mentioned).  I see doctors and nurses being condescending and failing to treat patients like they are whole people, not just a medical issue.  I see patients that have become either passive, not willing to contribute to their healing,  or demanding, looking to game the system for meds, attention, or both. So it’s the attitudes and perceptions of both patients and providers that inform the behaviors and words that contribute to poor communication in healthcare.

Since I’ve been a patient, provider and administrator, I see healthcare communication from a wide angled lens, and there’s plenty of blame to go around. I continually find myself wishing that those delivering care would just get back to the basics of listening to our patients, spending time with them, learning what they value (it’s not always what we value).  Patient facts and histories are accessible in that electronic record that everyone’s always typing in, but that doesn’t mean their healthcare team knows or understands them.  How many times does a patient have to tell their story when they enter the healthcare system, and not really be heard?  It’s like having to give your name, address and phone number to the 5th customer service rep in a row on one call with Comcast (you know you’ve all been through some similar bureaucratic labyrinth), it’s so painful.

Not only does the healthcare team often fail to give personalized care or communicate well, but that lack of relationship contributes to unnecessary poor outcomes.  Communication is well documented in the literature as a top contributor to errors in the healthcare setting. Patients go to clinics and hospitals in their most vulnerable moments and trust caregivers to be their lifelines. But way too often they receive a misdiagnosis, have unnecessary procedures, or experience other mistakes that could have been prevented by a better partnership with the patient and family. Patients are left feeling helpless, scared and confused. People don’t want to have to second guess everything the healthcare team says, but how else are they supposed to feel when they have these experiences?

Communication goes both ways and patients’ actions contribute to the breakdown of communication as well. Some patients are fighting back like ornery little toddlers who know their mama’s on the phone.  They know that they don’t have the system or their provider’s full attention so they’re acting out.  Either by advocating for themselves in a way that puts the provider at odds with them or nodding their heads at appointments and doing whatever they want when they get home.

Many patients hear medical advice given during an appointment, receive instructions for medications changes, get the suggestions to quit smoking and choose to do none of it. Sometimes because they don’t understand or have few resources and often because they just don’t want to. The demands some of them have when they come back to the hospital despite choosing to make any recommended changes leave staff feeling cynical and weary.

Doctors, nurses and others are trying to navigate this society of “problematic patients” and entitlement without passing judgment because that’s their job. But it’s often hard to hide the cynicism they feel.  They see people who make unhealthy decisions throughout their lives and then have to deal with the expectations of how they’re supposed to fix everything. So they enter future encounters with patients carrying the weight of this distrust of patients (because they’ve been burned so many times before) and that negatively impacts whatever current communication they’re having. And the cycle continues.

Providers need to listen beyond the patient’s heart sounds and get to the heart of their values, fears, and barriers.  The healthcare team needs to be open to the fact that their ideas for the patient may not necessarily be what the patient wants.  They need to approach patients NOT as medical “problems” or in a cookie cutter approach but as people with lives outside the healthcare setting.

Patients need to realize that they are a part of their healthcare team. The choices they make in their daily lives will affect their health.  Accessing the healthcare system and demanding outcomes will not make up for the years of wasted decisions.  However, accessing the healthcare system and asking questions- not because they do not trust the provider, but as an advocate seeking to fully comprehend what is being presented to them, is beneficial in preventing mistakes and getting the kind of care they value.

The relationships that would actually promote true healing are not found in quick visits with a provider telling the patient what to do and the patient going away doing whatever they want.  There needs to a partnership at every level. The “us versus them” mentality will continue to exist until both patients and providers can see themselves as  a cohesive team, coming together with mutual respect, dignity and honest communication to get the most favorable outcome possible.

I will continue to advocate for myself whenever I am a patient, and encourage others to as well.  As a provider of healthcare, I am making it my mission to treat every patient as a unique individual, one with value and holistic needs. Seek out those providers that do that for you, because they are out there. Every communication interaction is a rock or a chisel, they can either widen or close the healthcare chasm.

I am a nurse practitioner with a passion for patient advocacy, quality outcomes, and good communication between patients and providers.  These are my own views and do not represent my employers past or present.