Curbside Consult with Dr. Jayne 10/21/24

When I decided to pursue a career in family medicine, I saw the specialty as promoting three primary goals: health promotion, disease prevention, and helping patients live longer and healthier lives. As a third-year medical student, I had little understanding of all the factors that would be working against me in that pursuit.

I knew that there would be insurance companies that would put prior authorizations and other blockers in the way of recommended treatments. I knew that I would have challenges finding resources for patients who are without insurance and with low health literacy. I didn’t know that I would also be fighting an uphill battle against corporate America in the form of tobacco companies, giant food conglomerates, and many others that are reaping profits from reinforcing unhealthy behaviors and addictions.

As I moved into clinical informatics, we saw ways in which technology could help us do more with less and to better identify patients who were in need of health interventions. When we started looking for the needle in the haystack trying to find patients who had fallen through the cracks on preventive screenings, more often we found a giant pile of needles needing attention because so many patients had fallen through the cracks. Even after we had identified the patients, we still had to convince them to adopt healthy behaviors and undertake recommended screenings and treatments, which was an entirely different undertaking. It became discouraging to watch data pile up and not have the resources to act on it.

Fast forward to the world of wearables and the quantified self. We became excited about the ability to put data in patients’ hands on a daily basis, motivating them to make changes in their health status. The rise of wearables highlighted economic disparities when some patients had multiple different kinds of devices – from step counters to sleep trackers – and others were struggling with basic subsistence needs. As a primary care physician, that evolution created a bit of whiplash in the office as I moved from room to room. Some contained patients who brought printouts and jump drives so I could see their data. Other room had patients who were lucky to take a blood pressure reading at Walgreens once or twice a month. Although some employers and insurance companies developed programs to get devices to their patients, those were few and far between in my practice.

We are now 15 years past the release of the Fitbit, which made tracking more accessible for many, but I’m not sure that we are any healthier. Recent articles that looked at life expectancy show that the improvement curve of the last century has hit a slowdown, even in economically advantaged nations. Public health interventions and new medical treatments have been a primary driver of those improvements, but we still haven’t cracked the code on how to help our patients overcome many of the challenges that they face, from lack of health resources to the ability to cope with the decreases in function that come with normal aging.

Ten years ago, when getting together with physician colleagues over drinks, we could expect to talk about interesting cases that we had seen at the hospital, or we might be kvetching over student loan repayment. Now, we’re more likely to discuss how we are juggling our own health issues or the challenges of managing health needs for aging parents and loved ones. As part of a family whose members routinely approach 100, it’s a topic with which I have experience.

The article contains a discussion of research around life expectancy that has been done over the last three decades. The authors conclude that we’ve reached a point where it’s increasingly difficult to drive life expectancy upward. I found their discussion of the percentage of patients that could be expected to live to be 100 years of age most interesting. To make this happen, they note that we would need ways decelerate death rates among older people, and due to the costs involved in such a project, I’m not sure the world is ready to spend that kind of money.

Additionally, having been around plenty of people who are in their mid to late 90s, the ones I know aren’t terribly interested in radically longer lives. Although they have had tremendous life experiences, they have also had to grow used to living without their friends and loved ones and sometimes seeing their children and grandchildren predecease them. One of my relatives continually asks why she’s still here when so many others have gone, and it’s terribly sad. It’s certainly something that should be considered when we’re talking about changing how we look at medical interventions.

In thinking through this topic with the understanding of where we are with healthcare spending in the United States, it makes me wonder whether we have the right information to try to solve the problem of truly helping people live longer healthier lives, or whether we will continue spinning in circles.

We certainly know that some relatively inexpensive interventions, like vaccinations, help. However, we’re fighting an often losing battle in convincing patients to partake of these interventions due to conspiracy theories, fears related to debunked not-so-scientific research, and for some, a genuine belief that doctors only recommend vaccines because of personal profits. As a primary care physician, I can attest that the latter is most certainly false, but it’s difficult to convince patients. Improving nutrition is one of the areas that has the most potential to boost health, but it’s not sexy or exciting, so it languishes as a not-so-hot topic. 

We know that it costs money to improve patient health, whether through improved nutrition, health coaching, medications, or procedural treatments. However, because of our fragmented healthcare finance system, insurance companies pay for those interventions on younger patients but don’t realize the long-term savings, which sometimes don’t happen until patients are covered by Medicare. This phenomenon, along with our profit-driven insurance companies, drives the willingness of payers to try to deny treatment, which starts a cascade of activity by patients and physicians that unfortunately in some cases leads to everyone giving up before the patient actually receives the care that they need.

I’m still looking for the technology silver bullet that cuts through all this mess and matches the right patient with the right treatment at the right price at the right time. Maybe AI will help create that solution, but it’s also going to require a lot of individual commitment and political will that seems to be lacking.

Before we had so much data, we didn’t know if  we were doing a good job for our patients. Now we have lots of information, and although it shows that we do a lot of good things, it also shows ongoing deficiencies that still need attention. Maybe I can convince some of the smart folks who I work with to create an app to give me a weekly reminder of “great things we’ve found in the data and have been able to act on” so that the other findings we encounter don’t seem so discouraging. Although it might have been easier back when we knew less than we do now, knowledge is power, and it just reminds us of what is yet to be done.

How well does your organization drive outcomes using data? Are you helping move patients to improved health or are people running in circles? Leave a comment or email me.

Email Dr. Jayne.