Promoting Patient-Centered Care Through PBS

An Interview With Cardiologist Turned Documentary Producer Jennifer Mieres

Robert A Harrington, MD; Jennifer H Mieres, MD


March 31, 2015

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Editor's Note: A two-part documentary, Rx: The Quiet Revolution and Rx: Doctors of Tomorrow, 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, which are available here.

Executive producer and cardiologist Dr Jennifer Mieres talks to Dr Bob Harrington about why patient-centered care is the future of US Healthcare.

Robert A Harrington, MD: Hi. I'm Bob Harrington from Stanford University, and I'm here at the American College of Cardiology (ACC) meeting in San Diego.

At these meetings, you get a chance to catch up with friends from around the globe who are doing interesting things in the world of cardiology. Today, I have the great pleasure of introducing you to and having a conversation with my friend and colleague, Jennifer Mieres, a professor of cardiology and population health at Hofstra North Shore Long Island Jewish Medical Center and School. Thanks for joining us.

Jennifer H Mieres, MD: Thank you. It's great to be here, Bob.

Patient Centered Care

Dr Harrington: I think our listeners are very familiar with the notion of patient-centered care. Certainly, from a societal perspective, getting the patient more engaged with decision making around their health has become a central tenet of medical practice today. We're not quite there yet, but we're making progress.

Dr Mieres: We are.

Dr Harrington: You've done some really interesting work, including launching a series on television about this. Why don't you talk about that?

Dr Mieres: You know, Bob, in the United States we have great technology and we have great medications, but we have an overwhelming "tsunami" of chronic diseases. We've become great at preventing heart attacks or aborting heart attacks, and people now are faced with chronic diseases such as heart disease, diabetes, stroke, and kidney disease.

Consider the fact that 85% of health outcomes depend on everything else other than the medical interaction when the patients see us or come to the clinics. However, as a country and as a medical community, we have not focused on how we tackle that 85%, which will impact medical adherence, which will impact whether patients come for their appointments.

The idea in producing "Rx: The Quiet Revolution" was to highlight areas of the country where true patient-centered care is being done, where patients and people—person-centered care—have become empowered and have become true partners in their health.

Dr Harrington: Before getting into some examples, let's try to probe a few things here. I love how you said that people—forget patients—people spend the vast majority of their health-associated time not with us. This is where we have to start thinking about engaging people in healthy lifestyles. I know you're very much involved. I see you have a "red dress" pin on.

Dr Mieres: Yes, definitely.

Dr Harrington: You've been a longtime American Heart Association volunteer, really thinking about how we engage people in taking responsibility for their own health. It also reminds me of the whole question of the wearables in big data. For a long time I've wondered, why do we care about the single blood pressure when a person sees you or me when, in fact, what we ought to be doing is getting hundreds of blood pressures on a person during the course of their life.

Is that the sort of thing you're talking about?

Dr Mieres: Absolutely. It's where we enter into a contract or partnership with a patient. So if we can get Mr Jones, Mr Smith, or Mrs Jones to say, "Okay, you and I, Dr Bob, we're partnering." You can say, I know you have heart disease. My part is I'm here to help you to figure out what's wrong, to come up with a treatment strategy, and then you and I need to discuss what treatment strategy will work best for you.

Dr Harrington: In the context of your life, your values, your preferences...

Dr Mieres: Exactly. Customizing those lifestyle changes—when you take your medications, can you afford it? For example, often in my fellowship we see people come in with a heart attack. We write the prescription. We feel good as the doctor. Yes, I've saved your life. The patient went and got a stent. Then you write a prescription, and you say, come back and see me in 2 or 3 weeks. Here's a list of medications. Take one every day. Try and get 30 minutes of exercise.

We do not even begin to think that the person may be living in one room, they may not have a stove, they may not have access to healthy fruits and vegetables. They may not be able to afford their medications, let alone even understand the prescriptions. Plus, there may be cultural beliefs about medications. We have got to expand our thinking and the treatment strategy to really engage and customize care based on the individual needs.

Dr Harrington: It's interesting. I have a lot of things going through my brain. One was a paper[1] by John Spertus out of Kansas City a number of years ago where they looked at how many people were no longer taking clopidogrel after having a heart attack and receiving a drug-eluting stent. It's extraordinary, by 30 days it's 15% to 20% of people. And you say, how is that? Well, it's because we never thought about all of these other things that now that you list them are obvious.

How We Speak to Patients

Dr Mieres: Right. And we assume it's obvious. But Bob, just think of the way we speak to people, right? We speak medical jargon. "Yes, you've had a heart attack. I've put a stent in. You're going to do well. Take your beta-blockers," whatever. For example, we do not spend the time to ask: "Explain to me when you leave the hospital how are you going to tell your friends or family or loved ones what happened to you?" If we can even pause to do that health-literacy teach-back method, to say "tell me what you understand," we get insight into what they really understand.

Dr Harrington: The health-literacy one is a great comment because my reading of the health-literacy data would say health literacy is not a reflection of education.

Dr Mieres: No, it is not.

Dr Harrington: You can have highly educated people who are not health literate. You can have people with more limited formal education who are very health literate. Do you want to just touch on that for a minute?

Dr Mieres: I think we assume that because people may have a college education or master's or whatever [that they understand] and then we assume that people with a fifth-grade education or just a high school diploma do not understand. So we adjust our thinking, our language. For the MBA or for the fancy lawyer or whatever we speak in medicalese, right? We say, here's what you need to do, beta-blockers, etc. We just assume they understand.

Dr Harrington: Sometimes there's the perspective from their point of view that if the doctor is talking to me like this, I better not say anything because they won't think I'm smart.

Dr Mieres: Well said, and if I come across as not being smart I'm not going to get adequate treatment. Or they'll treat me differently.

Dr Harrington: They'll treat me differently, right.

Dr Mieres: And for the person who has maybe a fifth-grade or high school education, we simplify things, we speak more slowly, but it's not really us engaging with them—

Dr Harrington: Which would actually be a good thing.

Dr Mieres: Absolutely, if all of us in the medical community spent some time to ask, "Could you explain to me what you just heard? Or how are you going to explain this to your family? What can I do to help us stick to this treatment plan? How could we partner to do it?"

Dr Harrington: This really changes the dynamic of how we interact with our patients, doesn't it?

You and I sat next to each other yesterday with Dr Verghese as he talked in the opening session of the 2015 American College of Cardiology meeting about "I carry your heart." He really addresses this, doesn't he? We can have all the data and all the science in the world, but if we're not connecting it may not help.

Rx: The Quiet Revolution

Dr Mieres: Right. So coming back to the documentary, Rx: The Quiet Revolution, David Grubin, the 10-time Emmy-award–winning person, took this project. I went to him with a script, got my colleagues to partner with me. He was passionate about this; his father was a doctor. He grew up in New York City, and his father used to make house calls. He was disenchanted. He felt that we had lost the human touch in medicine. So this really appealed to him. He traveled from Maine to Mississippi to San Francisco.

Dr Harrington: To get a slice of the country.

Dr Mieres: Yes. What's interesting, Bob, is that there are parts of the country where people do not have access to the fancy academic medical centers, and they have had to make due. We went to Belfast, Maine, where we met Dr Loxtercamp. His father was a doctor. He still makes house calls. He has come up with a model with psychologists and other people in the medical team to help his patients. And he goes to them where they are.

Dr Harrington: The home is the ultimate patient-centered care, isn't it? Maybe in part it wouldn't be too trite to say he is the community.

Dr Mieres: Yes, and there's trust built in. Then, we go to Mississippi, where part of the University of Mississippi has partnered with the state to reach, to try to control the epidemic of diabetes.

Dr Harrington: Because of obesity, hypertension

Dr Mieres: There are lots of African Americans who do not have ready access to care. You have to travel 50 miles to get to a health center. What they have done is fascinating. They use iPads. They use medical technology, and so each patient with diabetes goes to the medical center, where there's not even a doctor. There are nurses.

Dr Harrington: And they get education live.

Dr Mieres: Yes. Your iPad wakes you up in the morning and says, what is your blood sugar? They have seen a decrease in ER admissions for diabetes. Once the patients understand, these people are going to churches spreading the word. So it's an innovative model using new technology.

Dr Harrington: And doing it in a way that's patient-centric, community-centric, and is bringing education rather than just telling people how to do it. In closing, tell the audience how do they see this? When is it going to air?

Dr Mieres: So on April 2 at 9:00 PM eastern on national PBS you can see Rx: The Quiet Revolution. We will have a website available. All the information about where you can get additional information about the film will be there.

Doctors of Tomorrow

We also have a companion piece, Rx: Doctors of Tomorrow, because you have this model of patient-centered care. When you and I went to medical school that was not the model.

Dr Harrington: We didn't talk about that.

Dr Mieres: The section about training doctors of the future will highlight a new curriculum from the Hofstra North Shore LIJ School of Medicine, where from day 1 the EMT training begins. So students get a chance to be first responders, going to peoples' homes, which they can factor into their culturally competent or culturally aware curriculum about medical care.

Dr Harrington: Absolutely fantastic. You've done it both from the patient perspective but also the provider's perspective. In particular, what I like is training the next generation so that from the very beginning we give them the skills to practice medicine in this fashion, which is really the way it needs to be practiced.

Dr Mieres: Where the patient is in the middle and the doctor may lead the team, but you have many other healthcare professionals be part of it.

Dr Harrington: And it is a team.

Jennifer, this is remarkable work, congratulations. We look forward to seeing the show. We look forward to following up to see the kind of progress you've had from this. Maybe we can have you back and have another discussion like this.

Dr Mieres: Thank you. A pleasure to be here.

Dr Harrington: Thanks for listening. We hope that you'll tune into this important PBS special.


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