Big Idea: Encourage physicians to take a big-picture view of each patient’s health
As an MD-PhD with specialties in neurology and psychology, Dylan Wint is good at digesting the abstractions of the patientpractitioner relations he’s observed over 20 years in his field. The top thing he sees as lacking across the medical profession is what he calls a “longitudinal approach” to patient care.
Here’s an example: A Las Vegas woman goes to see a cardiologist at a comprehensive medical practice out of town. While there, she falls and gets hit in the head by an automatic door. She tells her cardiologist about this during the exam, and he notices that she seems confused and woozy. So, he orders a PET scan of her brain. A radiologist reads the PET scan and diagnoses frontotemporal dementia. The woman returns to Las Vegas and sees her primary care doctor about the diagnosis. He refers her to the Lou Ruvo Center, where Wint gives her a thorough neurological exam, determining she does not have dementia; she had a concussion. Between the fall and the correct diagnosis, months pass, during which the woman and her care team are assessing everything through the lens of an illness that isn’t actually there.
“The cardiologist was doing the right thing to check her brain, because she did have an event,” Wint says. “But I know this patient. There’s nothing else that would lead to a diagnosis of dementia. The PET scan was the aberration.”
With a comprehensive view of the patient’s health, Wint says, a better approach would have been to wait six months and re-scan her brain to see if any signs of frontotemporal dementia persisted. As for the primary care doctor, he could have followed up with the cardiologist or radiologist who made the diagnosis and probed further to find out how they arrived at what should have been a surprising conclusion about his patient.
“That (used to be) the role of the traditional primary care or family doctor,” Wint says. “They didn’t just know you, they knew your family, lived in you neighborhood, know your history, the area. With the fracturing of healthcare we’ve lost that longitudinal view, the primary care physician who isn’t just sending patients out for consultations.”
One problem with regaining this traditional approach is it would require shifting how practitioners are rewarded. Rather than reimbursing them for the number of times they see a patient, or the time spent with them, pay would have to account for the quality of the care itself.
“There are small incentives for doing the extra things like talking to other providers and explaining test results,” Wint says. “Those should be core features of the system: coordination of care among providers, careful explanation to the patient of what’s going on.”
To get the larger picture, he suggests that the follow-up surveys patients get after every office visit ask further-reaching questions, rather than focusing on a single contact with an individual provider; for example, “How did this visit fit into your overall treatment plan?” and “How are you progressing?”
Zooming out even further, Wint says, the problem is that we don’t do healthcare in the U.S.; we do illness care. “Everything is centered around what happens when your health fails.”
“Health is a concept that starts at birth and fuses everything we do until the day we die,” he says. “To set up a system that willfully ignores that is setting up a system that’s bound to fail patients.” ✦
