I am a palliative care physician and I would like to talk to you today about health care. I'd like to talk to you about the health and care of the most vulnerable population in our country — those people dealing with the most complex serious health issues. I'd like to talk to you about economics as well. And the intersection of these two should scare the hell out of you — it scares the hell out of me.
I'd also like to talk to you about palliative medicine: a paradigm of care for this population, grounded in what they value. Patient-centric care based on their values that helps this population live better and longer. It's a care model that tells the truth and engages one-on-one and meets people where they're at.
I'd like to start by telling the story of my very first patient. It was my first day as a physician, with the long white coat ... I stumbled into the hospital and right away there's a gentleman, Harold, 68 years old, came to the emergency department. He had had headaches for about six weeks that got worse and worse and worse and worse. Evaluation revealed he had cancer that had spread to his brain. The attending physician directed me to go share with Harold and his family the diagnosis, the prognosis and options of care.
Five hours into my new career, I did the only thing I knew how. I walked in, sat down, took Harold's hand, took his wife's hand and just breathed.
He said, "It's not good news is it, sonny?"
I said, "No."
And so we talked and we listened and we shared. And after a while I said, "Harold, what is it that has meaning to you? What is it that you hold sacred?"
And he said, "My family."
I said, "What do you want to do?"
He slapped me on the knee and said, "I want to go fishing."
I said, "That, I know how to do."
Harold went fishing the next day. He died a week later.
As I've gone through my training in my career, I think back to Harold. And I think that this is a conversation that happens far too infrequently. And it's a conversation that had led us to crisis, to the biggest threat to the American way of life today, which is health care expenditures.
So what do we know? We know that this population, the most ill, takes up 15 percent of the gross domestic product — nearly 2.3 trillion dollars. So the sickest 15 percent take up 15 percent of the GDP. If we extrapolate this out over the next two decades with the growth of baby boomers, at this rate it is 60 percent of the GDP. Sixty percent of the gross domestic product of the United States of America — it has very little to do with health care at that point. It has to do with a gallon of milk, with college tuition. It has to do with every thing that we value and every thing that we know presently. It has at stake the free-market economy and capitalism of the United States of America.
Let's forget all the statistics for a minute, forget the numbers. Let's talk about the value we get for all these dollars we spend. Well, the Dartmouth Atlas, about six years ago, looked at every dollar spent by Medicare — generally this population. We found that those patients who have the highest per capita expenditures had the highest suffering, pain, depression. And, more often than not, they die sooner.
How can this be? We live in the United States, it has the greatest health care system on the planet. We spend 10 times more on these patients than the second-leading country in the world. That doesn't make sense. But what we know is, out of the top 50 countries on the planet with organized health care systems, we rank 37th. Former Eastern Bloc countries and sub-Saharan African countries rank higher than us as far as quality and value.
Something I experience every day in my practice, and I'm sure, something many of you on your own journeys have experienced: more is not more. Those individuals who had more tests, more bells, more whistles, more chemotherapy, more surgery, more whatever — the more that we do to someone, it decreases the quality of their life. And it shortens it, most often.
So what are we going to do about this? What are we doing about this? And why is this so? The grim reality, ladies and gentlemen, is that we, the health care industry — long white-coat physicians — are stealing from you. Stealing from you the opportunity to choose how you want to live your lives in the context of whatever disease it is. We focus on disease and pathology and surgery and pharmacology. We miss the human being. How can we treat this without understanding this? We do things to this; we need to do things for this.
The triple aim of healthcare: one, improve patient experience. Two, improve the population health. Three, decrease per capita expenditure across a continuum. Our group, palliative care, in 2012, working with the sickest of the sick — cancer, heart disease, lung disease, renal disease, dementia — how did we improve patient experience?
"I want to be at home, Doc."
"OK, we'll bring the care to you."
Quality of life, enhanced. Think about the human being.
Two: population health. How did we look at this population differently, and engage with them at a different level, a deeper level, and connect to a broader sense of the human condition than my own? How do we manage this group, so that of our outpatient population, 94 percent, in 2012, never had to go to the hospital? Not because they couldn't. But they didn't have to. We brought the care to them. We maintained their value, their quality.
Number three: per capita expenditures. For this population, that today is 2.3 trillion dollars and in 20 years is 60 percent of the GDP, we reduced health care expenditures by nearly 70 percent. They got more of what they wanted based on their values, lived better and are living longer, for two-thirds less money.
While Harold's time was limited, palliative care's is not. Palliative care is a paradigm from diagnosis through the end of life. The hours, weeks, months, years, across a continuum — with treatment, without treatment.
Meet Christine. Stage III cervical cancer, so, metastatic cancer that started in her cervix, spread throughout her body. She's in her 50s and she is living. This is not about end of life, this is about life. This is not just about the elderly, this is about people.
This is Richard. End-stage lung disease.
"Richard, what is it that you hold sacred?"
"My kids, my wife and my Harley."
"Alright! I can't drive you around on it because I can barely pedal a bicycle, but let's see what we can do."
Richard came to me, and he was in rough shape. He had this little voice telling him that maybe his time was weeks to months. And then we just talked. And I listened and tried to hear — big difference. Use these in proportion to this.
I said, "Alright, let's take it one day at a time," like we do in every other chapter of our life. And we have met Richard where Richard's at day-to-day. And it's a phone call or two a week, but he's thriving in the context of end-stage lung disease.
Now, palliative medicine is not just for the elderly, it is not just for the middle-aged. It is for everyone.
Meet my friend Jonathan. We have the honor and pleasure of Jonathan and his father joining us here today. Jonathan is in his 20s, and I met him several years ago. He was dealing with metastatic testicular cancer, spread to his brain. He had a stroke, he had brain surgery, radiation, chemotherapy. Upon meeting him and his family, he was a couple of weeks away from a bone marrow transplant, and in listening and engaging, they said, "Help us understand — what is cancer?"
How did we get this far without understanding what we're dealing with? How did we get this far without empowering somebody to know what it is they're dealing with, and then taking the next step and engaging in who they are as human beings to know if that is what we should do? Lord knows we can do any kind of thing to you. But should we?
And don't take my word for it. All the evidence that is related to palliative care these days demonstrates with absolute certainty people live better and live longer. There was a seminal article out of the New England Journal of Medicine in 2010. A study done at Harvard by friends of mine, colleagues. End-stage lung cancer: one group with palliative care, a similar group without. The group with palliative care reported less pain, less depression. They needed fewer hospitalizations. And, ladies and gentlemen, they lived three to six months longer. If palliative care were a cancer drug, every cancer doctor on the planet would write a prescription for it. Why don't they? Again, because we goofy, long white-coat physicians are trained and of the mantra of dealing with this, not with this.
This is a space that we will all come to at some point. But this conversation today is not about dying, it is about living. Living based on our values, what we find sacred and how we want to write the chapters of our lives, whether it's the last or the last five. What we know, what we have proven, is that this conversation needs to happen today — not next week, not next year. What is at stake is our lives today and the lives of us as we get older and the lives of our children and our grandchildren. Not just in that hospital room or on the couch at home, but everywhere we go and everything we see. Palliative medicine is the answer to engage with human beings, to change the journey that we will all face, and change it for the better.
To my colleagues, to my patients, to my government, to all human beings, I ask that we stand and we shout and we demand the best care possible, so that we can live better today and ensure a better life tomorrow. We need to shift today so that we can live tomorrow.
Thank you very much.
The healthcare industry in America is so focused on pathology, surgery and pharmacology — on what doctors "do" to patients — that it often overlooks the values of the human beings it's supposed to care for. Palliative care physician Timothy Ihrig explains the benefits of a different approach, one that fosters a patient's overall quality of life and navigates serious illness from diagnosis to death with dignity and compassion.
Timothy Ihrig advocates for an approach to healthcare that prioritizes a patient's personal values.
Timothy Ihrig advocates for an approach to healthcare that prioritizes a patient's personal values.