Healthcare: First Principles

Uhrm, your  energy is low and you feel that faint scratch in your throat - you're sick. You call the doctor, visit and describe your symptoms. She listens, remembers what to do in your scenario, looks in the EMR for anything relevant and gives you some medicine to take. You take the medicine,  follow her advice and, if everything goes normal, you're better.

Individualized, effective medicine needs to be built from first principles.

As the simple opening illustrates, you can fit healthcare into 5:

• Data in
• Data out
• Do something
• Diligence
• Direction

Data in - What Do we Know?

Your comments to the Doc

I don't know about you, but I feel extremely under qualified when I'm describing symptoms to a healthcare professional. Is this really the level of sophistication we want: my crude memory & language in a compressed timeframe, describing the most complicated symphony of moving parts that exist in the universe?
"Uh, my stomach kinda hurts, in like this area but a little bit here too sometimes..." I feel like a Neanderthal explaining how an iPhone works.

And yet - no one has more motivation to get well or is better at being you than, well, you.

Your data

Ah, but my data will make up what I can't describe! I have an Apple Watch that monitors my every heartbeat plus the incredibly sophisticated, modern technology within the healthcare system. On top of that some of the world's most trained and compassionate people are listening to it, right? Unnforrtunately... time constraints in the visit annndd...technological sophistication in the delivery of that data are going to make the actual use of that info lean you closer to cutting-edge 1990 tech than 2020.

Research to add data to the state of medical knowledge

In addition, the pushing of the boundaries of what we know about the human body and what treatments work define the limits of the problems we can solve. We need more knowledge. We need better explanations.

https://www.creatingbuilders.com/the-beginning-of-infinity/

Clinician's capture of the state of medical knowledge

Your doctor will have spent 10+ years in medical education and then will spend time on top of their day job absorbing the latest research above. They will be limited by the level of awareness they have of the cutting edge of medical knowledge and then filter that to the area of your input and data – ultimately using it to inform the next step.

Data out - What does it Mean?

Diagnosis

Barring additional testing, in the short time frame of your visit your doctor will choose the most likely diagnosis. That diagnosis is key because without it, your insurance won’t pay for anything & your doctor and their staff need funding to stay viable.
The necessity for that diagnosis code is completely OK as long as your diagnosis exists  - otherwise you have to fit a square peg into a round hole, which is (often) still better than nothing.

Doing something - Giving/Getting Care

Now, let's do something. This is the full medical industrial complex here. From pills to procedures it can fit into a manageable number of categories.

There are four loose dimensions that whatever you need to "do" stretches across:

• More expertise (specialists)
• More equipment, staff & a building that holds it (facilities)
• More time to treat (therapies)
• More data to gather (diagnostics)

Mapped it looks something like this:

There is significant overlap but simplicity requires some tradeoffs, here is a bit more about each:

Specialists

• e.g. Cardiology, Psychology, Vision, Dental, the experts who use the latest knowledge to provide you visits, diagnoses, & procedures.

Facilities

Acute care - overnight facilities.

• ER: whoa, we need to do something now, get in here and let's stabilize you.
• Acute Inpatient: you are admitted officially to the hospital & you're staying overnight.
• Long term care: things like skilled nursing facilities (SNF), Rehab, Nursing homes that require staff & support for a longer span of care.

Outpatient - within the day facilities.

• Sometimes it is for a surgery, sometimes for a therapy that needs the special building, equipment and/or staff.

Therapies

• Things like: chemotherapy, talk therapy, physical therapy, et al.
• Rx: the medicines you take on a schedule over time.

Diagnostics

• Imaging: MRI, PT, CAT, PET scans
• Labs: additional blood draws, tests, urine, etc.

Diligence - Patient Self-responsibility

After your treatments, it is up to you - as it was before your encounter with the healthcare system.

Take your medicine, follow your treatment path, seems easy but there is enough lack of follow-through that there are services like care management that can be worth providing to help people along in courses of treatment.

This category (including before any treatment is needed) is also where all prevention and some of the most promising areas of individualized medicine take place.

Direction - the Business of Healthcare

Finally, this infrastructure needs to exist so you can access it in the first place. Rules and regulations, certifications, administration provide the arena so there is someone there to help when you need it.

Everything you hear about our "broken system" of Fee For Service or the move to Value Based Care tends to discuss this section. While it is worth noting that people come from all over the world to get service from the US healthcare system – the system is also the biggest thing preventing healthcare from being the kind that we all want for us and our families.  

Five Principles

That is the whole thing, as infinite as it feels sometimes, it starts with the basics: Data in, Data out, Doing something, Diligence & Direction. Some smart person once said, "Focus on the fundamentals & magic happens." If we start from basics it is easier to innovate toward the next step we need...

Disruption - Making Big Improvements to it All

Healthcare is so frustrating as an industry & so clearly less than what it could be that we know it is going to be at the top of everyone's mind, including in polls like this on twitter:

Talk to any person who has ever been sick and they'll say the same kind of thing:

• "How can my phone be so good at X & healthcare be so far behind!?"
• "Why can't I just scan my body and have technology tell me what's wrong, my car has a 'check engine' light - why can't my body?"
• "My [loved one] is suffering/suffered/dying/died I can't help but think they'd still be with us if we had a better healthcare system."

If everyone thinks this - why isn't it happening?

There are an ugly number of reasons why it is difficult & doesn't improve but...the motivating thing is that it is up to us, we are the ones who have to make it better. We have to lead from wherever we are using the most pragmatic steps we can to make the most improvement possible. The road to the future is paved with tech & there are possible, actionable strategies we can take to make a better healthcare, they are up next.