The Frontline Of Health Care Transformation

I wanted to start by asking a question that has percolated throughout the morning. I’d like each of us to take a moment and reflect on whether we know someone, perhaps ourselves, a family member or a patient, who was diagnosed with something life-threatening like cancer and came to see that experience as a blessing.

We’ve heard people describe it that way today. If you can think of someone who would characterize that diagnosis and experience as a blessing in their life, let me see a show of hands.

Most everyone, right?

As a physician who works with this population, I’ve seen that over and over again and wondered why. What is that about?

It really comes down to what we’ve been talking about. In those moments of crisis, people take a moment to realign their lives with what really, really matters to them. We’ve heard this all morning. It’s about being awake, being conscious and living every moment fully, whether you have a week, a decade or several decades.

That is the gift that can come from those moments.

Our obsession is figuring out how to design for that earlier. We’ve heard a lot of conversation about that this morning.

The question I have is: Can we blow up the way healthcare is designed? Believe it or not, the VA is committed to doing this. Can we actually design healthcare to help people live in alignment with what matters most?

Let me share something with you.

This is my slide, but I didn’t create it. I was in a Department of Defense and VA meeting, if you can imagine that, and they were talking about how to transform large systems and drive change.

The consultants showed this slide and said, “Here’s the problem with most large systems. When they try to change, they start from the bottom right. They identify circumstances they want to change and then try to drive large-scale transformation by moving up that side of the slide.”

It doesn’t turn out well.

Their point was that when an organization wants to drive large-scale change, it has to begin with its aspiration. What does the organization want to be? That aspiration then drives behavior, which ultimately affects circumstances.

I was sitting in the room listening to this, and I got very excited because I thought, “That’s what we do in healthcare.”

Our entire healthcare system is designed to begin with the problem, the circumstance we don’t like. If you see someone trained in the medical model, I’m going to write down your chief complaint. That’s how I begin. I create a problem list and develop a plan for your problems.

The whole thing is problem-based: Find it and fix it.

I thought, “This is the transformation we need in healthcare. This is the best slide I’ve ever seen.”

We need to stop beginning with what is wrong and completely change the conversation. We need to ask, “What do you want your life for? Whether you have a moment or a decade, what do you want to live for? What really matters?”

Imagine what could happen if we started there.

Because I’m so shy and reserved, I jumped up and said, “I have to say something.”

I shared that reflection about the slide during the meeting. Two or three months later, I was in another meeting when a woman approached me. She has since given me permission to share her story.

She said, “I want to introduce myself. I was in that DoD and VA meeting with you, and what you said about that slide changed my life.”

I said, “Really? Wow. Tell me more.”

She told me she had a chronic condition and needed to see her physician every three weeks.

She said, “I don’t enjoy it. It’s a pain, but I’m very compliant.”

You could tell from talking to her that she was very Type A and a high achiever in her career.

She said, “I go and do it because I’m supposed to. But I left that meeting and started thinking, ‘I’ve never asked myself that question.’”

We don’t usually ask ourselves that question until the end of life, as we’ve been discussing.

She began reflecting on what she wanted to live for and why she wanted to live.

She said, “In three years, I’m going to turn 50, and I’ve decided I want to climb Mount Kilimanjaro.”

I said, “Whoa. Really?”

She said, “Yes.”

The next time she saw her doctor, he said, “Okay, let’s talk about your labs.”

That’s what we do. We talk about the labs.

She said, “No. I don’t want to talk about my labs.”

He said, “Excuse me? That’s what we do. We talk about your labs, adjust your medications and then you come back.”

She said, “Nope. I want to talk about how you can help me reach the top of Mount Kilimanjaro.”

The doctor was taken aback, but kudos to him. After a few moments, he recalibrated and understood what she was asking.

She told me, “Now I cannot wait to go to my doctor’s appointments.”

For four years, her doctor had been telling her that stress played a role in her condition. For four years, he had encouraged her to incorporate stress reduction or meditation. For four years, she had said, “No way. I do. That’s who I am. I do.”

She said, “Guess what I do now? I meditate for an hour every day.”

She wasn’t doing it so her disease would improve. She was doing it so she could live the life she had identified and reach her aspiration.

Two or three years later, I was in a restaurant and saw her. She came running over to me and said, “I did it! I did it! I reached the top of Mount Kilimanjaro.”

I love that story because it illustrates how we can do this together in a systematic way.

We’ve talked about Atul Gawande, but I want to read one of the many quotes of his that I love:

“We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really, it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when disability comes, but all along the way.”

How do we design for that?

Despite how broken the bureaucracy can be, the VA is committed to radically redesigning healthcare and truly partnering with veterans. That’s my job within the system, which is kind of crazy, but also very exciting.

We have defined this approach as Whole Health. I’ve loved all the conversation today about wholeness.

Whole Health is an approach to healthcare that both empowers and equips people. We have to do both.

If we only change the conversation, people may become energized and develop a sense of meaning, purpose and aspiration. But if they don’t have the skills to relax, eat differently or move their bodies, it isn’t going to work.

They need both empowerment and equipping. They need the skills to take charge of their health and well-being.

For what purpose?

To live their lives to the fullest.

What does that look like?

This is our framework for what it looks like in a veteran’s life, in a person’s life. The person is at the center. Their mission, aspiration and purpose are at the center of the model.

Mindful awareness surrounds that because you cannot be proactive about your health and well-being without mindfulness and attention. All of this is grounded in the teaching and practice of mindfulness.

Then we address each area of self-care within the person’s life and health, together with clinical care.

The question we’ve faced is, “This is lovely, but how do we make it work?”

Simply shoving it into the existing medical model does not work. The model is not designed to do this.

Going back to Atul Gawande’s quote, we’ve misunderstood our job in medicine.

I’m going to oversimplify this a bit, but in our current medical paradigm, that bottom-right bucket, the “treat” section, clinical care, represents most of what healthcare in America is.

If we’re honest, it’s disease management. It’s find it and fix it. It’s a clinical care model.

That’s what we’ve gotten wrong.

Clinical care is important, and we need it. But I believe that before long, we’ll look back and ask, “Why did we ever think that alone was going to work? That’s ridiculous.”

We have been designing and piloting a different model for several years, and we are now deploying it across a large system.

There are three elements to this future health system.

The first is exploring what matters most. How do you partner with someone to discover that within their life?

We have peers doing that work, not clinicians. They are trained as Whole Health partners.

Once people feel empowered, excited and engaged in their lives again, whether they have one day or many years, they participate in well-being programs.

That is the equipping piece. They learn new ways to relax, eat, communicate, relate and care for themselves.

That work has to happen differently.

How often does it work when your doctor says, “Eat less, lose weight, move more. I’ll see you in three months. Let me know how that turns out”?

Not very often.

Well-being programs are critical.

Then there is the treatment piece.

This is happening now, and it is really exciting to see. It is turning people’s lives around.

And by the way, their clinical outcomes are better. By the way, costs go down because people are engaged in their own lives.

This is happening at different stages across the United States within the VA system.

There is so much noise and craziness surrounding everything else that, in a way, it’s good. One of my favorite phrases is, “You can’t have breakthroughs without breakdowns.”

The VA is in a major breakdown, so we’re taking full advantage of that and transforming healthcare while nobody is looking.

That’s what we’re doing.

My own reflections are very consistent with what I’ve heard today. I feel very much at home in this group.

When I trained as a physician, modern medicine began with the body rather than the soul, and the mind rather than the heart.

Yet we know that the soul and the heart are doorways to healing and to the health of the body and mind.

We are now at an extraordinary point in the history of healthcare where we can design for that and lead the way.

In closing, I’m going to show a short video. You may have seen it. It went viral ages ago, but I’m old enough to bring it back.

[Video plays]

I’m going to ask her to come back up and receive your applause.

Thank you. You’re amazing.

Thank you so much.