Finger Of Fate
How a Funny-Sounding Condition Transformed the Way A Doctor Thinks About Health and Health Care
Phillip Polakoff, MD, MPH, M.Env.Sc.
Executive Producer/Host, A Healthier Me
Consulting Professor, Stanford University School of Medicine
Recently, my left index finger turned black and purple and swelled up to roughly the size of a banana. It was hardly the first time something went wrong with my body — after all, with 71 years on my odometer, I’m way out of warranty — but this was the strangest condition I’ve dealt with, and as I’m about to explain, it’s the one that changed my life.
I came of age in Detroit, in the turbulent Sixties — amid racial uprisings, cultural shifts, Vietnam, and labor/management battles. I’d known early on that I wanted to help people, but taking on the whole world at once seemed a bit daunting. So, following in my father’s footsteps, I became a doctor — I figured it would give me the chance to do good, without doing any harm. Bear in mind, this was back in the days of personal relationships, land lines, and even — believe it or not — the occasional house calls.
I practiced medicine for about twenty years, and then moved into care management, on to product and network development, then business, policy, communications, and financing activities. I guess my high career point came several years ago, when I heard a rumor that I was on the short list for Surgeon General. For a week I walked around with my chest all puffed out to here, until my wife pointed out that a.) it was just a rumor, and b.) the list might not be all that short. But what I’m getting at is, during those four decades I explored pretty much every corner of the belly of the beast — the beast that is the American health care system.
And I don’t call it a beast by accident. Our system is the costliest in the world, but many of our outcomes aren’t any better than you find in third-world countries. We spend nearly a fifth of our gross national product on health care. It makes up 35% of the $4-trillion dollar federal budget, and that percentage is going nowhere but up. Which inspired the quote —
“You don’t have to be wealthy to be healthy;
however, you have to be rich to stay sick”
Of course, there’s a kid on the block. The Affordable Care Act (“Obamacare”) that provides health care coverage for many previously uninsured Americans, but without doing much to control the non-MD cost drivers of modern medicine: insurance companies, hospitals, drug companies and device manufacturers. Plus, it adds a whole new layer of bureaucracy. But it’s the law at this time and we — the doctors and patients — are concerned whether it is repealed and replaced. What’s next?
Naturally all of these changes had a tremendous effect on my own career. And now, forty years down this path, I felt farther away than ever from my goal of helping people — let alone helping them achieve the World Health Organization’s definition of health:
“A state of complete physical, mental, and social well-being,
not merely the absence of disease or infirmity.”
Frankly, it was pretty frustrating.
Okay, the finger. I was on a long assignment, traveling all over the country, accompanied by this big, black, throbbing cigar, consuming large amounts of Motrin . . . with no improvement whatsoever. I went to a rheumatologist I’d never met — a bright young guy — who ordered the usual battery of tests and X-rays to “rule things out,” such as infection, acute arthritis, or a fracture. There was no clear diagnosis, but he had to do something, so he prescribed an antibiotic, an anti-inflammatory, and a steroid. The scattershot approach. I tried all three for a while, along with ice and splints. The pain dropped from a ten to maybe an eight, but I was still pretty miserable and — frankly — scared.
Around this time I started hearing the word dactylitis, informally known as “sausage digit.” It’s a colorful description, but not all that cute when you’re trying to tie your shoes or button a shirt. Dactylitis is actually related to gout — which I’d had before — and it was probably caused at least in part by some lifestyle stuff, which I’ll get to in a minute.
I finished my travels and returned home to the Bay Area, where I went to another rheumatologist (also a stranger to me, but recommended by a colleague), who confirmed my suspicion: Sausage Digit. He injected it with prednisone, had me taking four pills a day, monitored my uric acid, and over the next several months the finger slowly, slowly got better.
Then, just when I thought I was out of the woods, I was plunged into a new kind of Trouble, with a capital T, and that rhymes with B, and that stands for what? Billing! Week after week, I was deluged with bills and Explanations of Benefits, each jammed with impenetrable numbers and codes. Week after week, I nearly wore out my nine good fingers writing letters and emails questioning the charges and EOBs, and wore my right index finger down to a stump dialing phone numbers that immediately put me on musical hold.
I also started getting calls — from accounting departments and, eventually, bill collectors! At some point I figured out that my insurance payments were being forwarded to the right provider, but to the wrong department . . . where they were promptly cashed, but not credited to my account. The provider side wasn’t communicating with the insurance side.
But whenever I complained (which I was getting very good at, by the way), I was informed that the system was set up ineffectively — and there was nothing they or anybody else could do about it.
To be perfectly honest, I wasn’t exactly guilt-free in this whole finger mess, either. I have my faults — my kids will happily provide you with a long list — and my lifestyle probably contributed to my “sausagus giganticus” in the first place. I’d been working too hard, traveling too much, not sleeping enough, eating poorly, drinking too much of the wrong fluids and not of enough of the right ones, and I was about 30 pounds overweight. Also, I never took the necessary medication to prevent the recurrence of my pre-existing gout. And during treatment, I didn’t always stick with my prescribed medical regimen. I mean, what doctor follows a doctor’s orders? So yeah, there was plenty of blame to spread around.
Anyway, after what seemed like a lifetime of calls, letters, and emails, everything got sorted out — more or less.
So my story had a happy ending, right? The finger’s nearly back to normal, and in some ways I even came out ahead. I now exercise five days a week, drink half as much alcohol and sugary beverages as I used to, I lost the thirty pounds, and occasionally, I even get nice comments about my appearance! (People were even complimenting my suntan, until I explained that it was a side effect of one of the drugs I was taking.)
And then, one day, it hit me. For all my insufferable griping and moaning about the finger episode . . . I’d been incredibly lucky! First, as part of the medical establishment myself, I had access to inside information and resources that put me miles ahead of the person on the street. And second, all I had was a bad finger — not a bad kidney or a liver or a lung, let alone a heart attack or brain cancer. I mean, I was an insider with a relatively non-serious problem — think of how much worse things are for an outsider with a serious problem!
So, I decided to get serious myself. In addition to changing my own life, I decided to swing for the fences: to tackle America’s health care crisis head-on.
I began by reading everything I could get my hands on. I was familiar with much of what I found, but my whole attitude about it was different now. To continue with the theme, the sausage in the deli case looks a lot different after you’ve been through the meat grinder yourself.
For example: before I turned things around by taking charge of my own health, I was often seen not as a person, but a patient . . . or even worse, as a body part attached to a patient.
Another thing: coordination of care is lousy. Have you ever felt like a pinball, bouncing from one provider to another, starting each relationship practically from scratch? Me, too.
Another one: record-keeping. Sure, Electronic Medical Records (EMR) presents us with one of the greatest technological advances since the microscope, but unless the record-keeping systems are well-designed, well-implemented, and well-integrated, all we’re doing is replacing analog garbage with digital garbage.
How do we get more personal data incorporated into our electronic records?
Another one: transparency on pricing and claims management. I was seeing charges of $200 for a simple injection, $250 for a ten-minute appointment, $300 for an x-ray . . . numbers that bore no relation either to the services’ fair price on the open market, or to the amounts eventually paid for them. Why do we do this?
I soon realized what probably everybody in this room realizes: a fundamental, generational overhaul of health care is desperately needed. And it can’t take the form of a single, one-size-fits-all solution — it must be a sea change in every aspect of health care: who can access it, how they’ll access it, what services they’ll receive, and how those services will be delivered.
Obviously we can’t predict in detail every one of those changes, let alone describe them, but we can be prepared for them — by fundamentally transforming the way we think and act.
These “actualized thought transformations” fall into three categories. Some are individual, others are societal, and some fall in between. But all are desirable, and I believe that none is impossible.
ONE: Value-Based, Not Volume
Switching from a fee-for-service to a value-based payment model isn’t just a good idea . . . it’s the law. The ACA requires it. Will it stay in place. It will mean bringing the current confusing, dysfunctional financial system more into line with that of other industries, where it’s been proven to work quite well elsewhere.
To cite just two examples: groceries and auto repairs. Would you keep patronizing a store that made it nearly impossible to determine the price of a can of corn, then increased the price before you got to the register? Would you stick with an auto repair shop if every time you went in for an oil change, they forced a entire engine overhaul on you? They’d both be out of business in a week.
Or as my father used to put it, “Never ask a barber if you need a haircut.”
TWO: Transparency, Not Opacity
Health care takes place in silos, whose occupants rarely communicate with each other, and only communicate internally when forced to. The generalists — primary care physicians — don’t talk to each other. The specialists are confined to their specialties. Patients are afraid to ask their doctors direct questions, and most doctors don’t do much to encourage them. Payers don’t communicate with providers, as I learned during my billing fiasco.
Better communication starts at the personal level. Instead of a rushed transaction between a doctor and a patient, can’t we transition to empathetic, ongoing relationships between two individuals? Physicians, nurses, behavioral specialists, physical therapists, nutritionists . . . and their patients . . . need to be in it for the long haul, not just for the time it takes to conclude a purchase and a sale.
Better communication is needed at the systemic level, too. Pennsylvania’s Geisinger Health System is based on what’s called “clinical integration,” which brings together physicians, hospitals, clinics, and researchers under one umbrella for everyone’s mutual benefit. The results so far are encouraging — where communication improves, health and health care flourish.
The digital era should be making all this communication easier, but so far the sheer tidal wave of data seems to be making it harder. Harvard professor Michael Porter got it right when he said we need to “build an information technology system that allows hospitals to harvest information, measure outcomes, publish their results, and share critical information with patients.”
Heck, if we go on FaceBook and get in touch with our high-school sweethearts in two minutes, shouldn’t the same technology allow us to get some big wins from Big Data? (By the way, I’ve never done that. But I’ve heard that other people have.)
THREE: Prevention, Not Cure
Everybody knows that primary care, early, is cheaper and more effective than specialty care, later. A recent USA Today cover story tells of how high-deductible insurance policies are forcing people to put off simple, cheap treatments until they turn into complicated, expensive ones. Passing up on a $20 prescription can easily turn into a $10,000 procedure in a hospital, and if an ER is involved, triple that.
Thanks in part to the self-help movement — and maybe to the stubborn, self-centered Baby Boom generation — we’re beginning to understand that though aging and disease are inevitable, decay is not. Roughly half of all chronic conditions are the direct result of behavioral choices, and there’s increasing awareness that small, consistent lifestyle changes in diet, exercise, and attitude can yield big, long-last results. Employers are starting to recognize this too, and should be encouraged to incentivize better behavior with rewards as simple as gym memberships or reduced insurance premiums tied to improved outcomes.
The shift from treating illness to keeping people healthy will of course require tremendous changes, and — to the extent they threaten the status quo of certain entrenched sectors — threatening ones.
Three mission imperative changes, I would put forth, are:
O Invest in the foundations of lifelong physical and mental well-being in our youngest children
O Create communities that foster health-promoting behaviors; and
O Broaden health care to promote health outside of the medical system
CALL TO ACTION
When I began this journey I wasn’t exactly clear on what my destination was going to be, but I’ve now identified it. What I’m after is nothing less than:
Better health –
and better care –
at a just cost –
And I’ve just outlined the transformation that I think will be required to get us there. But that transformation won’t just come about by acclamation — it requires something else as well.
I often talk about the “the the four P’s” — personal health, population health, public health, and place — and how they must all be dealt with jointly in order to improve any of them individually. But this won’t happen without a fifth P political will. I have to ask myself, and you: What will it take to align our collective political will? Do we have to break the bank for Medicare and Medicaid? Can we continue to have forever growing federal medical plans that we can’t afford? What will it take?
Well, first, we need to start with ourselves. If your plane’s in trouble, it’s not rude to put on your own oxygen mask first before helping the person next to you. So if you want a country with better health, and better care, at a just cost, start with yourself. Research your condition. Join a gym and have a proper diet. Ask questions. Actually follow your doctor’s orders . . not just some of them.
Then, once you’ve acted locally, act globally. Research your health plan. Join a group, and if you can’t find one, start one. Ask questions. Write a letter. Complain. (It worked for me!) Talk to anyone who will listen: your providers, your insurer, your hospital, your HMO, your employer, your union . . . journalists, NGOs, thought leaders, and especially your elected and appointed officials.
Some of the ideas I’ve advanced here may sound general, but they have to be. That’s because the problem is so broad that it requires broad solution sets, embedded with specific solutions.
As I said, I am committed and involved, both personally and professionally, to health transformation. I know we all can be, too. And if enough of us work together, we’ll achieve measurable success in living longer, healthier, happier lives.