Advocate Seeks a More Relational Journey to Health

Health-care reformers who focus on systems and analysis may be expert at troubleshooting problems, but they leave out the essential partnership that physician and patient require as they journey through the experience of ill health, says Dr. Abraham Nussbaum.

Nussbaum spoke on campus Feb. 9 at the invitation of the Center for Norbertine Studies (CNS). The chief education officer at Denver Health, Nussbaum focused on “Moving from Health Care Reform to the Renewal of Medicine.”

In the eyes of the reformer
Nussbaum, who is on the psychiatry faculty at the University of Colorado School of Medicine, first invited his audience to close their eyes and picture a hospital. He then asked if anyone had pictured an airport. This, he explained, is the way some health-care reformers believe hospitals should appear. Airports are well-run corporations where good things happen: The building is secured, time is regulated, communication is scripted, and relationships are professional and impersonal. 

Conversations about health-care reform today center around efficiently run programs, the insurance mandate and the question of Medicaid expansion. Hospitals are viewed as successful when physicians take a team-based approach that – similar to airplane pilots’ – is governed by checklists and oriented around troubleshooting patient needs. 

“The idea is that, instead of trusting people and personal responsibility, we are going to trust systems,” said Nussbaum. Operator error will always exist; systems are adopted in hopes that error will be reduced, he explained. “The goal is to increase value: safety, efficiency, effectiveness, timeliness, equity. All the goal is to increase value. And the goal here is to measure everything we can using industrial techniques to improve and to assess success by outcomes. There is some real good here, but it is not truly a transformation of medicine. 

“After all, both the value-based model [the reformer model] and fee-for-service models [past model] of medicine are built upon metaphors of manipulating the body and the parts of the body under the control of medicine.”

Divinity and psychiatry, literature and medicine
Nussbaum studied literature and religion at Swarthmore, theological studies at Duke Divinity School, and completed medical school and a psychiatry residency at the University of North Carolina. He served on the American Psychiatric Association committee that prepared “Mental Health: A Guide for Faith Leaders,” a resource for faith communities. In his practice, he strives to inhabit the roles described in his book "The Finest Traditions of My Calling: One Physician’s Search for the Renewal of Medicine,” which asks how he and his fellow practitioners can restore patients to health through person-centered care. 

The people he meets as patients are often at the loneliest moment of their lives: hospitalized after a suicide attempt or a psychotic episode. Drawing on his experiences in these moments, he co-organized an international conference, Walking Together, on the responsibilities that communities have toward persons with severe and persistent mental illness. 

From past to present: a brief history of health care reform
Modern medicine was formed through the work of physicians, Nussbaum told his CNS audience. It was Sir William Osler, physician (1849-1919), whose work on medical school curricula continues to impact the way hospitals are run today. The Oslerian model of health care is not that of an airport, in fact, but one of a schoolhouse, where the rooms of the hospital are classrooms and the physician is a dissector and a patient is a cadaver. Today, still, medical students explore cadavers before they see and assist living patients. 

Nussbaum explained, “When I went to medical school, my very first patient was a cadaver. On the first day of med school, I learned how to take an old man apart. It’s a very different orientation, and we owe this to Osler.” 

The model can also manifest as a physician in the role of a scientist and a patient as a subject meant for study. Patients are tested in a diverse set of ways in order to assess the function of the body. “Osler brought medicine out of quackery and out of an unscientific past. Osler, more than any other person, personified the idea that physicians should apprentice themselves to the sciences in order to become a physician.”

Today, the scientific method is still vital; data compilation and analysis is fundamental to medicine. Physicians spend time by the bedsides of patients and completing data sets for later analysis. In other words, they measure something to make it better. It’s a system wherein physicians can tend to view patients as machines in a setting where health systems work together in pursuit of health outcomes, Nussbaum asserted:

“The goal of measurement is to become more effective. The problem with medicine, health reformers say, is that we know what to do but we do not know how to deliver it. The way to get better [they say] is to learn from factories; to engage in standard work, team-based care; to adopt efficiency, techniques like Lean or Six Sigma.” 

Hope for the future 
Logic-of-choice models assume that health care is a transaction. But, Nussbaum said, “I don’t believe that you can purchase health the way you can other products. Nor can you enter into a contract that will guarantee predictable outcomes from our unpredictable bodies.” 

The logic-of-care models address how the patient can live with the body they were given, and gives the patient the option of selecting who cares for them and how they are cared for. Nussbaum likened this type of health care to his own approach to coaching his son’s basketball team. “Much of this is like basketball. None of those kids that I’m coaching has a chance at the NBA; not a real chance. But I can tinker and tweak their movements, their practice patterns, within the league’s rules and the rules of basketball. My job is to help understand each of those kids, to figure out how to get them to run faster, jump higher, shoot a little better. That’s my goal, fundamentally: to form a relationship with them to make them the best version of a basketball player that they can be.” 

The patient and the physician are on the same journey to make the body function as well as it can, even knowing that this function may be limited. 

“What all of the models [within the logic-of-care philosophy] have in common is that the heart of medicine is an encounter between two people,” concluded Nussbaum. 

It’s an idea that has aided Nussbaum in his quest to transform his own practice:

“I believe that the grounds for the renewal of medicine is to acknowledge the dark journey that those of us who are ill and those who are caring for ill are on. That, ultimately and finally, we are fellow travelers on this journey. Health care reform as it’s discussed in politics today is largely about making the switch from fee-for-service to an outcome-based model. But I believe that renewal will only occur when we stop swapping and transacting, when medicine becomes truly relational between the well and the ill.”

Dr. Abraham Nussbaum's full presentation on Moving from Health Care Reform to the Renewal of Medicine is available on St. Norbert College's YouTube channel.

March 7, 2017