Health for life

After my self-revealing experience (see my last post: "Placing My Trust") where I discovered that I had placed my trust in the experience of eating rather than in Jesus, Ive been doing more observing. What I have since noticed is that I not only use binging (unscheduled eating) to assuage my feelings of fear, I have similar trust issues during regular meals. I suppose that would be obvious to others, but was still another revelation to me.

I consider myself to be a "big eater." I like my meals to be on the large side. I often have seconds. I noticed on Saturday when I tried out a new buffet restaurant, that in the middle of my second medium sized plateful my body suddenly signaled that I was full and I could not eat another bite. I then paused and felt confused. I did not know what to do with the rest of the food on the plate. I didnt know what to do. I tried to be aloof and stop eating, but I could not keep from finishing the plate. I then got a piece of pound cake, too.

I did not actually notice that the trust issue had showed up again until I had finished eating, paid my bill, drove home, and walked into my front door. I had been thinking about what happened on my trip home and when I walked in the door it dawned on me that I had not trusted or obeyed my bodys very clear message to me.

When the full feeling hit, I really did feel confused. I could see that I was really full, but could not respond to that feeling with trust, and just stop eating. I allowed me to ignore my body message, ignore what was good for my health, and continue eating, by desire or force of habit, I guess. I dont have this one quite figured out, yet, but I know I need to address this issue. I have seen it many times before.

I have had the experience of reaching the full point, putting my eating tools down, stating that I was completely full, waiting while my companion/s went on eating and talking, and then picked up my tools and started eating again. I just could not leave food on my plate. It was as if the food was starring at me. Perhaps, I was the one doing the starring.

This response is emotional, and very strong inside me. It is not logical and Ive often felt defeated by it, but Ive not found my way around it... yet. I know there has to be a way to deal with this, and it seems, in my mind, to be a trust issue, too. I think it could also be habit. I think I may need some kind of "permission" to actually rely on my bodys message of "Im full" in a new way.

I am not sure a plan to simply "stop" when the full signal goes off will work, but that appears to be the thing that would make the most sense. I have actually tried that in the past with very little success. I would like to respond to the full signal as if it were the final truth in the matter. I realize how odd this sounds but I know that when it comes to emotion, logic does not always enter in.

A picture of a childhood incident has popped into my mind two or three times as Ive been discussing this. I kind of did not want to share the incident because Ive shared it before and it is "boring" to me, now, but I also think it may be significant to this discussion so here is the incident:

I was sitting in a high chair eating a bowl of oatmeal. My mother was standing at the kitchen sink doing dishes. I was old enough to feed myself so my mother had left that to me as she went about doing her business. I had eaten all that I wanted and was playing in my food. My body had told me that I was full and I did not want any more food, so I had just moved on to this new activity. I was happily copying what my mother was doing. She was wiping plates in a circular motion, so I started to stir my food in a circular motion as I washed my dish. I felt I was doing what she was doing and I enjoyed this play.  I really did not want any more food and felt happy to just be with her doing what she was doing.

She turned her head, saw me stirring my unfinished oatmeal and became irritated. She, with very angry body language, stopped what she was doing, wiped her hands, came over, sat down and started forcing food into my mouth. I was suddenly frightened of her. I remember kind of backing up in my chair when I saw her anger and I just opened my mouth as she started shoveling the food in. As the heaping spoonfuls of food were shoved into my mouth, I would let it come out and kind of drip down my chin, I did not want to eat this food, I was full. She scraped my face with the spoon and shoveled that in too. Over and over again. My skin was starting to feel sore from the scraping. She was doing this caully and not intentionally hurting me, but the sheer force of her intention was frightening. I remember deciding that I should remember to clean my plate and eat all my food so I did not have to experience this violation again. I decided to eat all the food on my plate in the future so she would never be angry with me for not eating, ever again.

I have recalled this incident many times before and thought I had dealt with it, but clearly my current eating actions still seem to be related to it and this decision of mine. I feel kind of weepy and tears are welling up in my eyes, so I guess I need to process this information until I find the break through. I remember a technique that Pastor James Chapman once taught me in a counseling session with him.

He showed me a way to think of a certain emotional response as an adult rather than as a child. If I step back and take on the parental adult role of counseling a child, I would probably tell that young girl that it is completely OK to stop eating when your body says it is full.

Stepping back to observe this scene with me as an older child that I can talk to, along with me as an adult standing side by side, watching me as a baby with my mother, I ask "adult me" what I would say to this child to comfort and help her gain understanding of it.

As I look back as an adult I recognize my mothers response. She was busy and had a lot on her mind. She may have had an appointment of some kind that she needed to get to and she wanted to finish these two chores (doing the dishes and feeding the baby) so she could move on to the next important thing. As I think about this, I realize that she may have been pregnant at the time, too. Maybe she was in pain and wanted to just sit down and rest. I have a younger brother who is three years younger than me, but there was also a baby that did not live in between my birth and his. So if I was anywhere from a year to eighteen months old, that would have been right during the time that she was either pregnant or had recently lost my baby sister.

Any one of those things would account for her short tempered actions. As I think about this and compare my older sisters babyhood to my babyhood, it is as if we were from two different families. There were four years between her birth and mine, and no babies that I know of between us, so she had four years of being the baby of the family. There was one very tragic event that happened between the time she was born and I was born, though. My oldest brother, Terry, had drowned two years before I was born. That was a stressful life changing event all on its own. So my mother (and father) had really gone through a lot, already. I also know that when I was born, my mother got pneumonia, and when I was about a month old, I got whooping cough. Near that time my father also had opened a small restaurant/cafe down town which was failing, causing additional stress in the family.

So what I might say to a toddler/child living through this would be something like: "Im so sorry that happened to you. That must have been very scary for you and you did the only thing you could think of. You made a decision that would help you avoid this kind of confrontation in the future. That was not only brave and thoughtful it was clearly the logical choice based on trying to manage a situation that a toddler should not have to manage.You lived through it, and made a plan for the future, too. Good job!

Sometimes we have to be patient with our adults. They are not perfect and your mom was definitely going through some tough times, then. Think about this: she did not beat on you, or yell at you. Look at what she did. She made sure you had enough to eat. She made sure you did not go without something essential to your health. Yes, it could have been done with a little more patience and tenderness, but your mom usually was very patient and soft spoken which is probably why it surprised and frightened you when she was less than her usual quiet self. You were barely a toddler when you made that life-long-lasting decision out of a seemingly dire situation. At least "dire" to a toddler.

Think about other toddlers that you know. They are pretty small. Do you think that letting toddlers make life long decisions is the best way to handle any situation? When you were a toddler, did you know that? No. You didnt. You used all the intelligence and information you could muster in that instant and in your baby mind, you did what you needed to do to survive. There was no one else there to help you, so you did what you needed to do. What a great kid you were, but dont you think that is too much responsibility for a toddler to have to take on? Why is that? Because toddlers cannot see the big picture. Toddlers are too young to be making major life-long decisions on their own. You would not leave that kind of thing up to a baby, now, and you dont have to leave that decision in the hands of the "toddler then," either.

That was a great solution, at that time, but that decision which helped so much in the past is no longer valid for your present reality. It is time to make a new decision about being full. Do you think it might be OK, for you, now, as a sixty-three year old woman, to give yourself permission to leave left overs on your plate? It probably would be OK for you to give yourself permission to leave the food alone whenever you, in your adult mind, can see that you are full.

Picture yourself getting the "full" signal and looking at your plate. First, relax. You are OK. You dont have to eat even one more bite. Being full is a perfectly valid response to having eaten your fill. Notice... this is YOUR fill and no one else has the right to decide whether you are full or not. 

Wow. That last sentence touched me deeply. I began to really cry and then remembered there is a little more to the story that I had forgotten. I remember telling my mother that I was not hungry. I was full, but she completely disregarded me and my state. This battle of wills was not going to be won by the toddler. My mother had reached her last straw and this little girl was not going to get her own way. My mother forced her way on me. She forced me to eat. Every. Last. Drop. No food escaped by dripping out of my mouth. She caully scraped that up too, and made me eat it. She was so angry and determined. She had become a force to be reckoned with. I was angry at this violation of me and so very frightened by her behavior, I never wanted to go through that again. I believed she was angry because I had not finished my food, but that may not really be the case. I believe she was angry because her plan had been side tracked. She may have been frustrated with her life and my childlike playing was just the last straw for her on that morning.

Wow. My mother was like that. Most of the time she was gentle and patient, but aloof. She did not hug us, nor kiss us, nor cuddle us. (She was raised that way, too.) She did not sit next to us on the couch. She never put her arm around us or even patted a hand. She rarely carried on a conversation with me, directly. She was always busy and preoccupied, and if she decided something was going to be a certain way, it was. This reminds me of the hair incident when I was about eight years old.

She wanted to give me a Shirley Temple hairdo. This was probably 1958 and Shirley Temple hair does had gone out of style before I was born, but she wanted me to have that stupid banana curl job on my head. I was completely embarrassed at the thought of it. I told her over and over that I did not want it. I begged her not to do that to me. I cried and begged some more. She told me over and over that it would be cute and I would look good. I knew I was going to end up looking and feeling like a putz. I already had to wear these horrible sturdy green shoes she bought for Susan and me, and also had to wear my sisters old clothes. I was not going to wear that hair do too.

She forced me to sit still in the chair while she did my hair. I gave in and folded my arms and waited, but I did not give up. I knew that I was not going to wear that hair out of the house. I knew I could not stop her from doing this, but I was not going to wear it, either. (By the way, my hair was very hard to style, it was not easy for her to make my thick straight hair look like it had curls.) Anyway. She finished fixing my hair and walked out of the room, I presume, to get some hair spray to keep it that way. As soon as she left, I took my hands and ran them through my hair pulling out all of her work. Then I sat there and waited. I knew I was going to be spanked but, frankly, my dear, I did not give a you-know-what. I would rather take a beating than to walk out the door with that hair do. When she walked back into the room, the other you-know-what, hit the fan. She yanked me out of that chair, began beating my bottom with her hand, and informing me that she would NEVER do my hair again. She never did it, again, either. I was on my own in the hair department after that.

There was the snow pants incident, too. She wanted me to wear them (My sister did not have to wear them.) I used. So she let me go to school that year without them. The next year I was wiser and wanted them because it was so cold without them. She used to get them for me. I knew I was screwed and I walked to school from then on with cold legs and feet. That was when all little girls wore dresses to school, so no matter the temperature my legs were bare in the ice and the cold. Pants were not introduced in high school until the year after I graduated in 1968. Snow pants were the only long pants that little girls were allowed to wear to school.

You know, not until this writing, did I ever fully recognize that my mother and I had battled like that. With her and me it was often a battle of wills and however it ended, "the decision was always final." When Mom made up her mind, or I had forced her to do something my way, she never changed her mind. She never gave in. She never repented. And she never forgave. She never said anything, either, but I knew what was going on. Looking back on this makes me feel really sad. I wish it had not been so difficult for both her and me.

I guess I must have been hard for her to raise. Drawing the line and taking a stand was not an every day occurrence, for sure, which is probably why I never noticed it before -- but I knew how to do it. I think she may have given in to me, much more than I realized before. But not until this writing did I recognize how much she resented that, too. In fact, I think she actually gave up addressing me directly -- although that could also simply have been her MO. I had not realized that, either. I know it must seem odd that I did not notice that, but Ive never looked at this in this way before. Perhaps that is why she used to say that it was easier to raise boys. Ha. Now I understand that statement.

I had not realized that I got my "draw the line" and "do battle" stance from dealing with her. I knew it was there, I just did not know where it came from. It was just, you know, part of me. I remember the foreman at the paper in Salt Lake City giving me a complement that I was both proud of and embarrassed by. He said with admiration in his face and a chuckle of pride in his voice, "You dont take s**t from anyone." I knew he was right. But, I also did not know what to do with that information.

One more thing. I know my mother resented my father, because she used to talk about him behind his back, all the time. As much as fifteen years after he had passed away, she was still talking bad about him like he was in the next room. Their relationship was not all one sided. My Dad had done some things that I find really harsh. I found out that both Susan and I told her we were tired of hearing it. I remember saying to her, that he was my father and I loved him, and that he had been dead for 15 years, when was she going to let go and forgive him? She just started to quietly cry. That was when she told me that Susan had said the same thing to her. I felt sad for her pain.

I had not realized that she resented me, too, or, at least, did not know what to do with me. She was often stern in odd places, but that is another story. I knew I did not trust her but I was never sure why I did not trust her. (Some incidents come to mind but that is for another time.) Perhaps that is why we did not have "conversations"... I remember being about 14 or 15 the first time she actually said anything to me in a conversational sort of way. Oddly enough, I dont recall what was actually said, I just remember being kind of flabbergasted that she had actually spoken to me like I was a person and I remember the exact place in the house that it happened, too.

Most of my life I was "the victim" and I did not understand that, either. Anyway. I am really quite pleased to have remembered and recognized these things. I would never want anyone, including me, to think less of my mother. I still love her and miss her. She taught me some good things, too -- we did not have these stand offs all the time, which is probably why the ones I have mentioned stand out in my mind. She encouraged our creativity and wanted us to be independent. She taught me to cook. She is the one who taught me about God, too. Even though it was the Mormon way, which I later gave up for the truth, it was she, who taught me that God was important, and that prayer works. She really was an amazing woman.

Nobody has "June Lockhart" for a mother. Not even June Lockharts kids. June played the mother in the TV series "Lassie" when I was growing up. I remember wishing that she could be my mother. She spoke to Timmy with sympathy and understanding and treated him like he was a valid human being with authentic thoughts.  I thought she was a little sappy, too, but I really envied Timmy. I say that June Lockharts kids dont have that mother, either, because that was a role in a play and she only had to be Timmys mother for 30 minutes once a week. Somebody else wrote every word she spoke. Anybody can be a perfect angel of a mother for 30 minutes once a week if they have a script!  LOL The rest of the time she is a human being with all the faults and foibles of any other human being -- and no script and no director to say "cut" do over -- just like my Mom.

Im not sure where this revelation will take me in my eating adventures but I hope that I will be able to give myself permission to be full and enjoy the feeling, the next time it occurs. I will have to exercise these new muscles and learn what it is like to actually leave behind any food that I am too full to eat. I kind of like those words, "Too full to eat." Im happy with that.

Im also afraid that all this may have no consequence. What if the next time I feel full, I simply do what Ive always done? I suppose I will have to walk through that one, too -- maybe every time I eat, until I get it down pat.

To sum up where I am, I feel like now I have the "why" and all I need is the "what" as in what can I do with this information that will end up giving me the desired result which is to stop eating after Im full? I think I need to get back into my book and see what the expert says.

I really do have the right to be full... and act like it without fear! 

So odd that all this "stuff" got attached to food.

Thank you, Lord for opening my eyes.

(I just ate dinner, and am feeling nice and full. What an unusual feeling. Ive never experienced it so well, so fully, so deeply and so long before. Amazing.)

Be back soon,

Marcia

You read the Disease Management Care Blog and use its literature-based links.  As a result, you know a lot about shared decision making (SDM).   Based on the randomized control clinical trial data that are regularly linked by the DMCB, youre ready to implement it in your network of primary care clinics.  You call your physicians together for a meeting, explain SDM is the best thing since the invention of the Woods lamp and ask them to er patients to the program.

Except for the part about the DMCB, thats what basically happened at the eight highly regarded medical institutions: Dartmouth-Hitchcock Medical Center, MaineHealth, Massachusetts General Hospital, Mercy Clinics in Iowa, the Oregon Rural Practice–Based Research Network, the Palo Alto Medical Foundation, the Stillwater Medical Group in Minnesota and the University of North Carolina at Chapel Hill.  The decision aids covered approximately 50 common conditions such as knee arthritis and prostate enlargement

And it didnt work out.

To investigate what happened, investigators at RAND interviewed 23 "key informants" from the 34 primary care sites that had implemented the Informed Medical Decision Foundations shared decision making program. The interviews were conducted between December 2010 and March 2011.  Their study is published in the February issue of Health Affairs.

Three barriers were identified:

Overworked physicians: given all the other health care needs of their patients, it was difficult to count on physicians to distribute the decision aids.  As a result, only 10%-30% of eligible patients participated.

Overconfident physicians: many doctors felt that they were already providing sufficient patient education or that their patients would not benefit from the decision aids.  Just telling the docs that this worked was not enough.

Underperforming EHRs: the state-of-the-art information technology could not flag potential patents, remember which individuals had been exposed to the decision aids or record the patients perences.

The answers?

Well, if the someone from the eight institutions had simply called the DMCB and asked, it would have told them about the many times it explained stuff to a roomful of physicians and had zero impact.  There also good peer-reviewed literature on why its so difficult to change physician behavior. 

The DMCB ultimately found the answer is to take physicians out of the work flow.

Thats what the RAND researchers found.  Based on their interviews, they recommend that if youre going to implement SDM in your clinics:

 Automate the process as much as possible and remove human decision-making from the process the triggered the decision aid.  That could be done on the basis of pre-existing clinical criteria or when a specialist erral had been arranged.

 If automation was not feasible, rely on non-physicians to trigger the decision-aid.  For example, office assistants could offer SDM to patients in the course of check-out.

Image from Wikipedia

Talk about a no win situation.  After seeing his "red line" go rudely unheeded, the President is facing the prospect of appearing weak if he does nothing or warmongering if he launches an attack.

Medical decision scientists ask: how did it come to this?

Mr. Obama is correctly admired for his "no-drama informed style of decision-making.  And good physicians, says medical science, should operate the same way.  According to this recent New England Journal article, consciously deliberative and logical approaches to diagnosis and treatment selection are far more reliable than the intuitive shoot-from-the-hip pattern recognition that used to rule the bedside.

Psychologists describe the latter as "Type 1" processing while the former is "Type 2."   Think George W. Bushs gut instincts over Iraqs weapons of mass destruction versus Barack Obamas disciplined rationality when he decided to attack the Bin Laden compound. He undoubtedly used the same methodology when he was pondering Syria.

But, thinks the Disease Management Care Blog, there are limits to brainy decision-making when the choices are overwhelmingly numerous.  In this retail business-oriented TEDTalk, Sheena Iyengar points out that dozens of options lead to procrastination followed by bad choices followed by low satisfaction. 

It can also apply to foreign policy. Given the vast array of pieces and potential moves on the Middle East chess board, little wonder that Mr. Obama would procrastinate for days saying he has "not made a decision," then apparently select an attack option disdained by even the New York Times and then engender even more second guessing by the very Congress that the President has repeatedly criticized as unreliable.

Ditto health care.  The downside to shared decision making is that an overwhelming number of testing and treatment options can lead befuddled patients to a "you decide, doc" mentality that leads the physician to regress to "Type 1" decision-making.

The DMCB isnt too sure how TEDTalks Dr. Iyengars suggested solutions can help the folks in the White House Situation Room, but the DMCB wonders if the national security staff shouldnt have done a better job of presenting the Commander in Chief with 1) a limited number of choices that were 2) more "concrete," as well as 3) arranged into categories with the 4) low complexity options offered first. 

That 4-fold approach could help docs and patients too.  The DMCB looks forward to additional research in the area.

In the meantime, there is one additional medical rule that has withstood the test of time that may also be useful in dealing with Syria. The DMCB offers it up to business and politicians alike: primum non nocere.

The Disease Management Care Blog recently attended a physician meeting that keynoted a U.S. Senator.  In his prepared comments, he admitted that he knew little about controlling health care costs.  Unfortunately, that didnt stop him from humbly paraphrasing the testimony of a famous economist:

"Find out what works," said the expert, "and do that."

Maybe some of the physicians silence that followed was an "aha!" reaction to the Senators insightful nostrum.  Some of it may have also been out of respect. 

The DMCB is sure, however, that most of the docs in the room were quietly thinking "You must be kidding me."

Such is the approach of the mandarins leading our federal health care institutions.  "Science and existing literature" says HHS Secretary Sebelius.  "Effectiveness" is the mantra of the Center for Medicare and Medicaid Innovation.  "Improving health care" is now part and parcel of CMS. 

Unfortunately, applying scientific evidence to the economics of health care delivery sounds easy enough until you get down into the weeds.  For a perfect example of that, consider the common condition of painful spinal stenosis among Medicare beneficiaries. According to this JAMA article, there were over 37,000 operations in this population at a national cost of $1.65 billion. 

Which begs the question: does spinal surgery "work," is "effective" and "improves health care?" Can the "science and existing literature" help us decide?

To get an idea of just how complicated the answer is, check out this Agency for Healthcare Research and Quality (AHRQ) research review on Spinal Fusion for Treating Painful Lumbar Degenerated Discs or Joints.  The conclusions from the abstract are:

Overall, limited evidence suggests that spinal fusion compared with physical therapy improves pain and function for adults undergoing fusion for low back pain due to disc degeneration. Because of insufficient reporting and variation in surgical methods used in the different studies, the incidence of adverse events (serious and minor) associated with fusion could not be determined conclusively. The evidence was insufficient to draw evidence-based conclusions for the benefits and harms of spinal fusion for patients with degenerative stenosis or degenerative spondylolisthesis of the lumbar spine. The evidence was also largely insufficient to draw conclusions about the benefits and harms of fusion compared with other invasive treatments or different fusion approaches or techniques.

In other words, there is some evidence that, compared to conservative treatment, surgery helps.  After that, its the stuff of caveats, statistics, evolving technique and myriad study limitations.

In fact, its so complicated that the only way it can be applied is by helping patients understand how the science applies to their unique circumstances and values.  Once the patient understands things, its a matter of letting that patient and doctor jointly decide on the best course of action.

That approach - in contrast to U.S. Senators musing on how we need a one-size-fits-all approach to what works - is called shared decision making and it can be applied to back surgery with considerable cost savings.

"What works?" asks the Senator?  The answer is for you to consider staying out of the way.

As readers may recall, the Disease Management Care Blog is a big fan of shared decision making (SDM). Using unbiased, state-of-the-art and interactive media that presents a set of treatment options, patients with the help of their doctors are surprisingly able to input their values, make trade-offs and come up with the best choice. Research suggests that patients tend, in aggregate, to be both reasonable and conservative.

The DMCB is also a fan of the ePatient movement.  Based social media, this is the networked and two-way sharing of medical information in a virtual community of like-minded patients that also facilitates informed patient decision-making. Compared to SDM, ePatients have been less well studied, but there is some good research that suggests that these on-line communities are remarkably disciplined and accurate. In fact, advocates argue that ePatient communities, compared to physicians, are better able to alert its members about the latest medical updates.

Which makes the DMCB wonder if the ePatient movement represents a classic disruptive innovation that is threatening the SDM business model.  Commercial SDM typically is made up of video content (much like a DVD) that is developed by credentialed experts and has to be updated periodically. Contrast that approach with the ePatient community (on-line, on demand whenever you want it) that harnesses the wisdom of crowds and is so organic, it really never stops being updated.

Think music CDs vs. iTunes. Or DVD movies vs. on-line streaming.

But the most important distinction? The former is being sold by physicians or content developers, while the latter is being given away.

The DMCB speculates:

The shortage of primary care services, increased cost sharing, spreading consumerism, the explosion of medical information, distrust of authority, ease of use for social media, less concern about privacy, the rise of self-educated experts and a curious immunity from actually having to make money all make the DMCB think that the ePatient movement is here to stay.  Its value will trump the inevitable anecdotes of waylaid web users, e-mistakes and death by internet.

In order to stay relevant, commercial shared decision support tools will begin to direct users to medical e-communities. Physicians will "outsource" their own SDM to online ePatients. This will give IBMs Watson a run for its money. Architects of clinical guidelines, point of care decision support, EHR portals and health information exchanges will successfully ignore the ePatient movement - for now.

On-line bulletin boards will be the first stop for any new symptom and to second guess physician advice. The doctor-patient relationship will turn into a menage a trois.

"eApps" will appear for the persons with diabetes, mothers of leukemics and the children of persons with Alzheimers.

Health insurer perred provider networks will have one more reason to die off.

e-Communities will add value in helping its ePatients figure out how to get insurers to cover services that would otherwise be denied.

Some mainstream health organizations will host ePatient communities.  Authentic and trustworthy ones will learn from them. None will successfully commercialize them.

Researchers will tap into e-communities to recruit patients for research. The pooling of users data for observational research studies will grow.

Unfortunately, this will exacerbate the medical digital divide for persons without reliable access to the internet.

Dr. Smith* was well known among the hospitals medical directors. Thanks to his superb training and busy clinical practice, this busy physician was convinced, thank you very much, that he had all the knowledge necessary to manage his patient population.

Summary quality reports, feedback and best practice advice he did not need.  He also loved pointing out that he wasnt being adequately reimbursed to deal with administrative hassles, many national Clinical Guidelines were based on faulty research, his patients were not "average," and his duty to his patients was to "first do no harm."  He believed in patient education but resented administrators meddling.

The medical directors werent about to use a "stick" and "de"credential Dr. Smith and kick him out of the network. The "carrot" financial P4P incentives they offered for quality measures were modest and comprised a only a small percentage of the physicians income.  They. Were. Stuck.

Enter the Affordable Care Acts Patient Centered Outcomes Research Institute (PCORI). Writing in the latest issue of Health Affairs, RAND researchers Justin Timble, Eric Schneider, Kristin Van Busum and Steven Fox reassure frustrated medical directors everywhere that PCORI will come to their rescue by ushering in a new dawn of clinical trial research.  The studies will be so good that Dr. Smith will change his passive-aggressive ways.

Dr. Timble et al point out that the reluctance of physicians like Dr. Smith to change their clinical practice is not surprising.  Payment mechanisms incent questionable treatments, much of the published medical science is riddled with ambiguities, even expert scientists succumb to a host of biases when they interpret study results and doctors are more interested in avoiding the risky downsides versus the upside benefit of new medical advances.  Last but not least, clinic-based electronic record decision support never fails to disappoint.

Fortunately, says these RAND authors, the PCORI is on it. Its sponsored research will transparently solicit stakeholder input and investigate all meaningful outcomes, including side effects.  When this high octane knowledge is combined with a dollop of rigorous guideline development, more gigabytes of information tech decision support and the luster of Obamacares payment reforms, uncooperative Dr. Smith will be transformed into compliant Dr. Smith.

Sounds good, but the DMCB doubts that sprinkling PCORI pixie dust on docs is the cure to what ails the health care system. In its estimation, the RAND authors and the editors of Health Affairs are only telling half the story.

The DMCB to the rescue.

Despite the authors enthusiasm, PCORIs well-meaning stakeholders will have to make real-world compromises on study scope, data collection and completeness. Their research methods and findings will never be completely immunized against healthy skepticism.  And while RAND scientists and the readers of Health Affairs are professionally invested in PCORI, how well it competes for the attention of practicing docs like Dr. Smith remains to be seen.

Financial carrots and sticks can be used to change physician behavior, but Dr. Smith will ultimately stay in the drivers seat thanks to a) a looming physician shortage and b) the prospect that total physician reimbursement will go down, leaving no room for incentives. While integrated delivery systems, accountable care organizations and physician-hospital alliances may (or maybe not) wring some dollars out of PCORI-based efficiency and quality studies, it remains to be seen how these big capital-intense organizations will share any precious leftover dollars with their docs.

The population health management (PHM) service community has a better answer.

While high quality research conducted under the supervision of an expert professional class has its place, they know its ultimately up to the informed patient to make decision.  A considerable body of research, much of which would pass PCORI muster, has shown that shared decision making using a personal physicians advice is remarkably adept at reconciling imperfect research with patient values and preferences.  This, in turn, increases quality and reduces unnecessary costs.

The DMCB has seen countless physicians like Dr. Smith welcome the help of team-based nurses who can help his patients. He may call it "education," but theyre engaging patients in science based decision-making and taking a lot of work off of Dr. Smiths hands.