Reviving a Classic Model in Medicine

In the mid 1970’s Dr. George Engel pioneered the biopsychosocial model of medicine. The model is pretty self-explanatory, yet I used to get lectures about it as a child while I was trying to eat Honey Nut Cheerios and watch Spider-Man. You see, my father trained under Dr. Engle at the University of Rochester and has practiced behavioral neurology since that time. So as in a scene from A River Runs Through It, I learned about Dr. Engel’s gospel at an early age.

I am haunted by the report that our federal Department of Health and Human Services (HHS) is considering handicapping metrics for physicians who work in difficult psychosocial communities.

Only a federal bureaucrat would commission a study to validate Dr. Engel’s four-decade-old work. A lay reader of Wikipedia can easily understand the impact upon HHS or Medicare biomedical metrics for physicians who choose to serve challenging psychosocial communities. Yet the New England Journal of Medicine and Harvard School of Public Health weigh in suggesting we need further study and more metrics with increasing fudge factors.

There is no need to complicate the debate over our nation’s healthcare crisis with more noisy commentary.  These proposed and increasingly complicated metrics will require employed non-clinical PhD or MPHs to decipher. Buried in the middle of the NEJM text is the only significant statement in the entire piece, “we need to make strides in addressing the underlying issues themselves.”

Caring for a diabetic in Detroit is very different than Grosse Point. The biology is the same, however the psychosocial challenges are completely different. As a medical student I was quite fortunate to have a Henry Ford Hospital primary care continuity clinic in Detroit. My patients had psychosocial challenges a kid from the Brahmin Boston suburbs could never imagine. For example, residents of Grosse Point or Hingham do not contract syphilis when their spouse comes home from prison. Nor do they have transportation barriers in seeing their physician or diabetes nurse.

Rather than HHS further complicating their already arcane metrics with fudge factors for physicians in challenging communities (requiring data wonks to interpret), why not keep it simple and address the whole patient?  We need to provide support for psychosocial barriers to health. This would take money away from healthcare programs that folks in Hingham and Gross Point enjoy but there is no need to further disenfranchise those Americans who are already struggling.

Our Veterans Healthcare Administration remains the most enlightened healthcare system I have seen regarding Dr. Engel’s model.   By imbedding psychologists and social workers within primary care clinics, those PCPs can provide warm hand-offs to qualified professionals to break psychosocial barriers to a veteran’s health. This is a model that should be duplicated elsewhere in the public and private sectors as it improves access and reduces downstream costs of chronic diseases such as smoking, substance abuse,  diabetes, and obesity.  Unfortunately, it appears that HHS, NEJM, and Harvard are moving in a different direction.

The Importance of Human Resources in Customer Service

A contracted mobile CT scanner brought in to support a VA hospital CT construction project sits idle in a parking lot due to a lack of human resources. With a rumored cost to taxpayers of approximately $45,000/month there are no technologists available at the institution to run the scanner and provide veteran access to this important imaging service. Furthermore, the absent human resources has prevented timely access to CT services during second/third shifts, and weekends, affecting the Emergency Department and inpatient veterans who need scans. Many of these after-hours studies are being outsourced to a local private hospital, requiring the added cost of ambulance transportation.

Meanwhile, daytime scans are being performed on an in-house low quality 16 slice hybrid SPECT/CT machine, potentially displacing veterans who need nuclear medicine exams.

As the idle mobile CT unit continues to collect dust in the parking lot one employee quipped, “I hope that thing is gone before the snow flies or it will burn.”

Let’s hope it is another mild winter. More attention needs to be paid to the relationship between VA Human Resources and veteran access.  As Human Resources is the link between internal customers (employees) and external customers (veterans and their families), their mission is critical.

A Duty to Scan

Imagine a Veteran’s Hospital where taxpayers have provided tens of millions of dollars of CT and MRI equipment. Imagine that hospital has a 8-12 week backlog of veterans who would benefit from these exams and salaried radiologists ready to interpret the images and pass that knowledge back to the organization’s customers.

Continue to imagine there is a bottleneck; the technologists needed to move veterans through the scanners are not available. Does that Veteran’s Hospital have a duty to hire as many technologists as possible and maximize the capacity of those scanners? Does the hospital have a duty to scan, and is it negligent not to do so? If a principle mission of the Veteran’s Hospital is responsible stewardship of taxpayer resources, the answer is yes. Let me explain.

Currently our Veterans Administration has the ability to outsource clinical duties to private hospitals when demand cannot be met internally. However, when they do so in Radiology, taxpayers must reimburse a small piece of the investment that the private hospital made in their own scanner. This is known as the technical component of the fee and that private hospital will send a bill to the taxpayer that includes it. If the scanner at the VA were being run at peak capacity this technical component paid to the private hospital would be justifiable. However, if there is idle capacity in the hardware at the Veteran’s Hospital, taxpayers are effectively buying something that they have already purchased.

Stewardship of taxpayer resources would suggest there is a duty to scan within the VA system and that outsourcing of imaging is only appropriate when that VA equipment is being run on weekends and second shifts. It is critical to have an administration and Human Resources department that understands this duty.

Veterans Affairs Mission Statement: Set and Fixed in Metal

I took a course in marketing recently. The first lesson taught was the importance of knowing who you are as an organization. This knowledge, distilled into a mission statement, can serve as the central piece of what should be ongoing internal and external dialogues. If you do not know who you are, you are going to have difficulty with your employees and customers. But this knowledge alone is not enough. When you are not transparent about your needs, values, and intentions it is difficult to partner with anyone, be they the person at the counter, in the next office, or on the other side of your bed.

Most hospitals market poorly; this is often a product of not clearly defining, adhering to, or effectively translating their missions. Perhaps it is not surprising that our largest heath care system, the Veterans Administration, often struggles with marketing. Here is the VA mission statement as imbedded in a recent job posting.

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So, the VA’s mission goes back to the days of President Lincoln. While he may have been our greatest president and one of our greatest leaders, I am sure he knew nothing about modern medicine. Furthermore, the statement relegates women to the role of grieving spouse in a military where only men go into battle.

Thankfully, orphans of veterans are significantly less prevalent today than in Lincoln’s time. The vast majority of our veterans return alive; but the wounded are missing limbs and carry psychological scars that are not easy to diagnose or treat. These injuries greatly impact their families and children in a way Lincoln could not have imagined.

The job posting which carries this mission statement tries to make up for its inherent sexism with the tag line about caring for “the men and women who are America’s Veterans” but succeeds only in making it more awkward and wordy. Our military’s and country’s current values of equal opportunity and modern health care are not supported by this mission statement. How many outstanding healthcare workers and potential employees might be discouraged by its implied lack of sensitivity, or worse, awareness? It is time for our Veterans Administration to update their mission statement. In the process of doing so, they may clarify, inform, and unify their sense of purpose and identity. Distilling this awareness into a clear and concise mission statement may in turn elevate the organization and enhance communication between their employees, within the American culture, and with their veteran customers.