I recently came across a short, interesting TED book called The Upstream Doctors by Rishi Manchanda. The book is about going upstream to unroot the reasons for why patients (and their communities) fall sick. While most of the action is usually when we solve medical problems that stare at us, it might actually benefit healthcare (both in terms of keeping people healthy and saving costs) if we keep going upstream. In a telling example, the author discovers that a patient had constant migraine headaches that would never go away in spite of a variety of pain medications, CT scans, MRIs, blood tests and so on. After questioning her about where she lived, he discovers that there was mold in her house and that caused the headaches. Further, her son also had developed asthma. Upstream questions regarding someone’s housing/ environment/ stress levels aren’t usually part of an office visit – may be they should be.
Medicine has become so specialized that each specialist is concerned only about their specialties. I once asked a dermatologist, if he would spend the time to understand why a patient has developed a lesion on his hand, beyond simply fixing the lesion and conducting a biopsy. He responded saying that the patient is coming to him for a specific problem and if he doesn’t address that he could end up developing a hole in his hand. Nearly every specialist thinks this way – that it’s their job to focus on the specific problem that they are trained to solve and not go beyond. But inside the body, all systems are interconnected and patient doesn’t feel symptoms in an isolated manner. It’s usually expected that it’s responsibility of the family doctor/ general practitioner to go upstream and discover the underlying reasons. But since most of our reimbursement system is based on episodes – who would pay the doctor to go upstream and stop the reasons that result in these problems?
Even though pay for performance and ACOs are attempts at thinking of patients as a whole, fee-for-service thinking is inherent in how we work – even beyond medicine. We notice those people who fix complex problems more than we recognize those who work day after day to prevent problems from occurring. When picking challenging tasks, people go downstream because that’s where the problems are most visible – there’s action, drama and excitement. But may be we should all start looking backwards and going upstream (medicine or otherwise) to recognize problems before they occur. And may be we should create our reward systems around such thinking.