COMMENTARY

Rx: A Quiet Revolution: Healthcare as It Is, or as We Want It to Be?

Reflections on the PBS Special

Mark E. Williams, MD

Disclosures

March 31, 2015

Editor's Note: A two-part documentary, Rx: The Quiet Revolution, will air on PBS on April 2. Reflecting on his physician father's practice and the move away from hands-on care in contemporary medicine, the documentary's award-winning director, David Grubin, highlights a range of innovative practice models from Maine to Alaska. Medscape asked a number of our experts to preview the film and offer us their reactions and opinions about how well the documentary depicts the healthcare system as they know it and live it.

In this commentary, Mark E. Williams, MD, an internist, geriatrician, and professor of medicine at University of North Carolina, offers us his perspective.

This inspirational video seems to be a personal tribute to the producer/writer David Grubin's father, who was a practicing physician during the 1950s. The basic premise is that there is a new breed of healthcare professionals quietly spreading across America who embody the values and commitment of previous generations of healthcare workers.

In the video, we are treated to four vignettes that span the geographic United States and a variety of ethnicities.

The first vignette introduces us to a dedicated solo practitioner from rural Maine who makes house calls, rides a moped, sings in a choral group, leads a substance addiction group, and reminds the film's writer of his dad. He is warm, caring, and compassionate, and just the type of person anyone would want for a primary care physician.

Next is a community health clinic in rural Mississippi that uses 1990s technology to coordinate the complex care of individuals with diabetes mellitus. We meet Annie Ford, who is charismatic, charming, and inspiring as she shares her new routine using an electronic tablet and her commitment to take charge of her illness. With basic teleconferencing, an electronic record, and the telephone, an interdisciplinary team manages numerous persons with diabetes mellitus, with the goal of coordinated care for chronic diseases.

The results are impressive: striking reductions in both emergency department visits and blood sugar levels. The inference is that blindness, strokes, heart attacks, amputations, and need for dialysis (the outcomes most meaningful for the patients) will also be reduced. If the evidence is available, it would be a very powerful addition to the arguments being advanced by guidelines and experts.

Our third stop is the On Lok program in the heart of Chinatown in San Francisco, which is a model "nursing home without walls." On Lok began in 1971 and uses a capitated reimbursement model for long-term care. Given the almost 45-year history of this program, why has it not been more widely adopted?

One possibility is that it requires individuals to be "dual eligible" for both Medicare and Medicaid, a point that is inferred but is glossed over in the film. Not everyone can take advantage of this Program of All-Inclusive Care for the Elderly (PACE), creating a type of "Goldilocks phenomenon," to paraphrase Dr Robert Kane: To qualify, you cannot be too sick or too well, and you must be poor but not too poor. One of my recently widowed patients was forced to leave a PACE program because her husband's pension, when added to her meager funds, put her slightly over the threshold of Medicaid eligibility.

It is true that transfers to the hospital from On Lok are less than from traditional nursing homes. It is less clear whether this difference is related to the "quiet revolution" or to financial and reimbursement metrics.

The final vignette shares an inspiring program in Alaska, where Native Americans were able to build a more responsive program than the preexisting Indian Health Service. The resulting healthcare system creates "customer owners" in a type of healthcare cooperative. The very remote sites have community health aides who follow a protocol with cookbook approaches (the words used in the video). A pharmacy vending machine and traditional healers complement western medicine.

We hear heartbreaking stories of separated families where children were sent to boarding schools and forbidden to speak their native language. Not surprisingly, rates of domestic violence, and physical and sexual abuse, increased.

A senior administrator informs us that the most important determinant of good health is "self-confidence," a goal of this healthcare model. Perhaps this advice is correct, but I doubt that it holds if you live close to a toxic waste dump and do not have access to clean air, water, and food.

In summary, I enjoyed the video and watched it twice. It is very well-crafted and sincere. And we meet real people who have addressed real challenges in their local areas.

On an emotional level, it is inspirational and moving, but it is confusing at the same time. Some of the images showing the writer filming the scenes (for example, in an automobile with the Maine physician) seem gratuitous, and every vignette reminds us that his father was a very special doctor who had a black bag.

What are we supposed to take away from the video? Is it a call to action; a reassuring glimpse at a rosy future filled with creative, compassionate healthcare workers quietly changing the healthcare landscape; a nostalgic look at the past; or some combination of these views?

Are these really examples of the future? How can we be sure? How many solo practitioners are in the clinical pipeline, and how many remote rural communities are desperate for a primary care provider? The Alaskan community health aide tells us that the healthcare responsibility was so stressful that she moved from her remote community of 100 to one of 300! A worker from Mississippi tells us that she is tired of Mississippi ranking near the bottom of the scale for obesity and diabetes mellitus. Perhaps there are additional social and societal issues to consider.

There is absolutely no argument with the essential truth that health has to undergo a revolutionary transition from the Ptolemaic "hospital-centered universe" to a Copernican "patient-centered universe." But is a quiet revolution really under way, or are the examples presented the most durable attempts to deal with these challenges from past decades?

The video ends with a poignant statement from David Grubin (to paraphrase): "If only my father could have seen this film." There is no doubt he would be very, very proud of his children (and especially David), but it is less clear whether he would view this as representing a new breed of health professionals. Perhaps the real need is for personal, caring human interaction.

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