We continue with the second segment of my interview with Dr. Diane Meier, Professor of Geriatrics and Internal Medicine at Mount Sinai School of Medicine and Director of the Center to Advance Palliative Care. If you missed it, you can catch up on part one here.
Q. In 2008 you received a MacArthur “Genius” Fellowship—an honor often bestowed on artists and writers. So I wanted to spend a little time talking about that. What are your thoughts on the role creativity plays in science & medicine?
The scientific method is a tool to get closer to the truth, but it’s only a tool. Creativity comes in ‘what are the right questions?’ How do I align knowledge or perspectives on the truth from multiple disciplines or ways of thinking to get a better comprehension of the truth. It’s sort of like the “Rashomon” scene. It’s like if you only had one person’s perspective, you’re not getting the whole story.
What the MacArthur and RWJF pushed me to do was to employ approaches to improving the quality of care that reached to many other disciplines besides medicine… So one of the key drivers of implementation of palliative care was developing the business case for it… understanding that if it was not going to save key entities money or bring in more money, no one had the spare resources to do this.
I had never had to think about that before… it was all about quality, right? But, of course, the real world is the real world and the ivory tower academics are very often completely disconnected from the real world. So I had a crash course in health care financing…. Unless you understand that, you will not get social change, you will not be able to implement new models.
The second major business principle that totally transformed my thinking was that of marketing, and, in particular, social marketing. I thought of marketing as something you do to part innocent people from their money… but actually what marketing is is just effective communication. The principle of marketing is ‘understand your audience and what they care about.’ Because unless you’re talking to them about things that are salient to them, they’re not going to hear you, and they’re not going to change their behavior.
It was the application of tried and true business principles to scaling this innovation that made it work. It wasn’t enough to be right. It wasn’t enough to have data in the literature that says this improves outcomes—that’s important, but that’s 1% of the battle. You publish something and it’s often 10-15 years before practice starts to adopt that, and we cannot afford that kind of delay… so it’s not enough to publish the data, it’s not enough to know the right thing to do and have it sit on the internet gathering dust, you have to do something with it… you’ve got to convince people that it’s worth their while to change their normal behavior—what they were trained to do 10 years ago—to move in a different direction.
You’ve got to convince them it’s worth their while even though it’s unfamiliar and uncomfortable both by showing them that financially it’s at least neutral if not cost-saving, and by speaking to them in a way that they can hear, that matters to them… that doing this will actually help them.
So, for example, in palliative care we have message strategies that are different for every audience. Not because we’re manipulating the audiences but because the audiences themselves are different and have different concerns.
With physicians a lot of it is, ‘we save you time.’
The one thing that doctors are desperate for and never have enough of is time—to do all the things they’re trying to do on behalf of their patients… If we (palliative care specialists) can help deal with the constipation, the pain, the shortness of breath, the depression, the anxiety, the ‘I don’t remember what he said to me last week,’ ‘my family’s falling apart, we don’t have enough money to pay for the prescriptions…’ then that doctor can focus on what he was trained to do.
It makes the doctors more efficient and more effective and feeling like they’re actually doing what they were trained to do. That’s the benefit to doctors, and the patients get better care and have better outcomes—which is also a benefit to doctors.
Q. What about administrators?
Right. What’s the benefit to the hospital? Completely different audience, right? To the hospital it’s reducing length of stay and reducing cost per day. Hospitals get paid on a lump sump capitated basis for every stay, so anything that controls cost once that patient is in the hospital is hugely valuable to the hospital. The hospital also cares about reducing 30-day readmissions. That’s not the doctor’s metric, that’s the hospital’s metric.
The hospital cares that palliative care teams can help patients develop sustainable, safe discharge plans so they won’t come back to the ER in 2 weeks in a pain crisis…
Well, what matters to patients and families?
What matters to them is that when they pick up the phone and call somebody at 3:00 in the morning, somebody calls them back who knows something about their situation in a timely manner. It matters that they feel there’s a safety net around them when they’re home. That’s what matters to patients and families—it’s a completely different audience.
And we have yet more message strategies for policy makers. Palliative care demonstrably—with strong science behind it—improves quality and reduces cost. So it markedly improves the value equation. That’s how policy makers think.
If you said all of those things to any one of these audiences they’d glaze over after 5 seconds because it’s just not relevant to their day-to-day life and things that trouble them at three in the morning.
I think it shows respect and concern about your audience to try to understand where they are and what keeps them awake at night.
The CEO is worried about meeting payroll and Medicare payment cuts and union stuff and quality stuff—very different than what the patient and family are worried about. They’re worried about themselves—quite appropriately. And the physicians are worried that they’re going to get home at 9:00 again tonight and not have dinner with their families.
Q. Isn’t it draining for you trying to create the kind of systemic change your outlining? I mean, where does that energy come from?
I don’t know. For me it’s nourishing and exciting, because it works. So I don’t feel like I’m wasting my time. I mean, look at what has happened in this country in the last 12 years. I feel so lucky to be doing work that—I mean, I hope I’m not naïve, but I genuinely believe that it’s making a difference.
I’m so lucky to be doing this kind of work and to have learned the tools, the competencies, the skills that other people who have been doing social change work for years already knew but that wasn’t part of my training.
It’s interesting that this isn’t a core part of training of physicians & nurses, because it should be. It really should be. Because somehow we’re trained that once you publish, you’re done. And that’s not right.
Once you publish you’ve only just begun, if you actually want the care of human beings to improve. It’s the kind of 30,000-foot view of social change, but I’m not talking about population health—though palliative care is about population health—but fundamentally it’s about the experience of one human being and their family as they live with one or more serious illnesses, often for many years, in a health care system that really doesn’t know how to help with that situation.
Q. You’ve been awarded the American Cancer Society’s Medal of Honor for Cancer Control. Has cancer affected you personally?
Nobody in my immediate family with cancer, but I have been heavily influenced by people with cancer as my patients.
As an intern on my ICU rotation, I had a 22-yr-old with acute leukemia, who was only a couple of years younger than me at the time. And it wasn’t supposed to be that way. You know, it’s one thing to take care of an 87-yr-old, it’s another thing to take care of a 22-yr-old.
And we did all the things you do in an ICU, we put in a lot of central lines and a Swan-Ganz catheter and pressers. From a “learning technical skills” standpoint it was very challenging and gratifying, but we couldn’t save her. And she died in our ICU.
So I carry that memory with me, because there was no focus on her quality of life. There was no focus on pain, on helping her understand what was happening to her, helping her talk to her parents about what was happening… there was no focus on the parents’ grief and dismay. We didn’t help them say goodbye. We didn’t help them say, ‘I love you.’
We didn’t know how.
Our job was to keep her alive as long as possible, and that’s what we tried to do. So all these other really important opportunities were completely blown. So I think about that.
We’ll break from the interview here and pick up again in part three. Dr. Meier shares two powerful, transformative stories from her practice as a palliative care physician.