Rethinking Population Health
With highlights from Uncaring, by Dr. Robert Pearl, this article illustrates ways in which public health concepts can change outcomes for patients. Alyssa Dean builds on Dr. Robert Pearl's ideas about changing physician culture. Using concepts from public health she illustrates ways to improve the patient experience.
We’ve heard it a million times—the U.S. spends more than 20% of their GDP on healthcare, and our population has a lower life expectancy and worse health outcomes than any other high-income nation. So, what are we doing to fuel this disparity? We are applying our energy to the debate orchestrated by politicians on how to pay for healthcare. We’ve been doing this for years and we are all OVER it. As we are in an era where people can cultivate change as a collective and collaborate more than ever, now is the time for us to rethink about what we are missing in our healthcare — patient education, active participation, and self advocacy being major topics in particular.
One man very eager to move medicine with his book, Uncaring, author Dr. Robert Pearl accentuates the shortcomings of our healthcare system due to the passed down social characteristics of the physician culture—the set of beliefs and norms that are expressed by physicians.
Dr. Pearl is a board-certified plastic and reconstructive surgeon, currently a clinical professor of surgery at Stanford University and faculty member at Stanford Graduate School of Business. He was also the leader of Kaiser Permanente for over 18 years— one of the longest standing integrated managed care systems in the US. I think we can conclude that he doesn’t lack the credibility to speak out.
With his experience, his passion for transforming our healthcare system is unique in a way, as his perspective combines the business side of our healthcare system with the insider knowledge of clinical care as a physician. In Uncaring, Dr. Pearl provides personal, heartfelt stories to further demonstrate the internal discrepancies of our healthcare systems. He allows us to see the subtlety of how the issues of physician culture manifest in reality.
This book is his way of awakening not only physicians to their own harsh realities, but for patients to understand how to ignite change on their own level as he believes it will help push the culture of medicine and healthcare in the right direction—patient centered, value-based, and team oriented.
Resembling Dr. Pearl, I too have a unique perspective. Although instead of having the physician or business perspective, it is as a patient and with a public health viewpoint. Academically, I have been conditioned to analyze the health of people and their community, evaluate their resources, and examine their behaviors in order to implement the best courses of action for improving their health. From my perspective, it is not only the resistance to change on the part of the physicians imbedded in the culture of medicine or the business model of the healthcare industry that is hindering our transformation, but rather it is that we are simply not applying these learned public health concepts to disease management on an individual level. Is there a way for healthcare and population health to come together?
Implementing healthy community approaches relies on the understanding that environments and systems influence health behavior, and that social determinants of health influence a person's life and are the force that drive health outcomes. Simply stated, a public health perspective provides the ability to understand the environmental dimensions that make up an individual or community. Analyzing the neighborhood and built environment, health and healthcare accessibility, social and community context, education level, and economic stability allows us as public health professionals to see a person’s story and recognize why they are the way they are, and why they do the things that they do—making it easier to identify what needs to be done to activate behavior change to improve their health, and their life.
Concepts alike are what public health professionals have been using at the population level for so long, but what we have yet to do is bring it down to that of the individual. The key to creating cultural change at the community level—starts with changing the behaviors of an individual. How do we change behavior? By understanding someone’s circumstances, and with this arises so many questions, for someone who’s learned public health.
I want to put this into perspective for you. Let's take Bob, who has diabetes for example. Applying a public health approach would look like:
Does Bob have access to healthy food? Does he shop at Dollar General because he is low income? Does he have transportation to get to the grocery store? How is Bob’s health literacy on the subject of diabetes? Does he know how to check his blood glucose, really? Does he even know what diabetes is?
A physician doesn’t examine these factors, or coordinate alternatives. They look at the diagnosis, diabetes, and tell the patient, “you need x to help it.” The physician culture in a nutshell is that they are the most unwilling to change this. However, Dr. Pearl’s placement on these failing social characteristics only go so far. It is my belief that what is worse isn’t their inability to change, but the fact that we’ve come so far in taking health care away from the individual. What we are lacking now, is the people to fill this gap. This doesn’t mean Pearl didn’t find a devastating issue within our healthcare system, he most definitely did, but just as important is the lack of self-sufficiency we as patients possess.
Let's take a look at public health from the 1980s to the 2000s—a time that was referred to as the era of Health Promotion and Disease Prevention that focused primarily on individual behavior and disease detection populations. The action framework for this time placed more emphasis on individual control of decision making, and when examining CDC data, heart disease was falling from the 80s to 2000s. Today, it is starting to rise again. Is our new focus away from individual heath a contributing factor? Being self-sufficient in your own health is almost a taboo subject to consider today as we’ve become so dependent on the authority of physicians, government entities and the emphasis placed on the efficacy of pharmaceuticals — none of which actually help change patient behavior.
Heart disease is our nation’s number one cause of death and kills more than 600,000 Americans each year. What is being done to change this? Who is to blame? Pearl places blame on the cardiologists for not accommodating patients at all hours and that it is the delay in care that puts patients at higher risk for death. Others blame the fact that medications need to be more affordable and accessible. I blame the lack of education that people have in order to make different lifestyle choices. I blame the lack of compliance with a steady medication regime. Most importantly, I blame the lack of ability people have to engage in managing their own health, like using a blood pressure monitor to make sure it is within normal range or knowing healthy food alternatives that’ll help make them feel better.
This lack of education is what is referred to as health literacy--the capacity of an individual to understand basic health information and services to make appropriate health decisions. Individuals with low health literacy, like described above, lack the skills and are in need of just basic health education to understand and retain medical information, understand their illness and how to prevent a future recurrence, be active in self-care and medication regimes, and engage in follow-up treatment. Did you know that one’s health literacy is directly linked to their health outcomes? I know physicians do not consider this, as they do not take the time nor have the time to educate. I know Dr. Pearl would agree.
Today, nearly 36 percent of adults in the US have low health literacy and a majority of them are considered lower-income. If we continue with the way we are doing things now, what will happen in our future? Bridging the gap between public health concepts and healthcare can be done, but we need more collaboration at the most primary level with professionals who pick up the slack of what is not being done—health education and the guidance of being active in your own care.
What will soon be the new pathways of preventative medicine and undoubtedly fundamental in our future as 70 to 90% of most common chronic diseases are a result of lifestyle behaviors, health educators and health coaches have the power to improve overall health outcomes and activate patient autonomy, leading to sustained behavior change. All physicians have to do is embrace a more team-based approach to care. By doing so, we could strengthen partnerships between community-based organizations, hospitals and health systems, and local health departments which would help communities cultivate healthy change on a scale that is bigger than just the individual.
Imagine—patient education workshops with health educators and health coaches guiding patients to a state of self-care disease management with the collaboration of a primary care physician, as a team. With this effort, we have the ability to bring back patient autonomy, prevent a heart attack, and take pressure off of our overworked physicians all while lowering healthcare costs and creating a stronger return on investment for not just communities, but the country. Hey Dr. Pearl, the physician culture is one thing, but creating healthy communities by encouraging and engaging people to be more active in their own healthcare will create a truly organic health-care system.