The Healing Art in Medicine

Though he comes from a family of pediatricians, Dr. David Dosa, a health researcher and Assistant Professor of Medicine at Brown University Medical School, chose geriatrics. He realized early on that there was a coming healthcare crisis for the elderly demographic. As the US population ages, there will be an unprecedented demand for end-of-life care and services for the elderly from a system that’s largely unprepared to meet it.

David Dosa

It’s his ability to maintain simultaneously a general and a focused perspective regarding the issues of geriatrics and the practice of medicine overall that makes Dosa an interesting physician to profile. More importantly, he brings the clarity of an accomplished, best-selling writer to emphasize the human element that drives everything we face in healthcare. Very much alive to the general trends that make the aging population such a challenge to our collective mandate to promote good health, he still knows the importance of providing a level of care tailored to each patient.

Dosa cites this belief as the biggest takeaway from his book, Making Rounds with Oscar: The Extraordinary Gift of an Ordinary Cat. The staff at the nursing home in Providence, Rhode Island, where Dosa served as a consulting physician considered Oscar a typical unfriendly, self-possessed cat until they noticed that he had the peculiar habit of cuddling up next to those patients whose deaths were imminent. Although there may have been a

physiological reason for Oscar’s behavior-one theory is the cat could scent the biochemicals released by disintegrating ketone cells in the terminally ill-the sheer human effect was most prominent, giving comfort to the dying as well as family caregivers and staff.

As he studied Oscar during his time at the facility, Dosa took this idea to heart-and realized that sometimes the best thing a physician can do for his patient is just to be there and listen. Dosa articulated this view in a July 2007 article published in The New England Journal of Medicine, and subsequently in his book, which was on The New York Times bestseller list for eight weeks and subsequently published in 20 languages worldwide.

A deep appreciation for the patient as a human being governs how Dosa practices. When asked about his work with vet- erans and with the elderly, he explained that it was the wealth of individual experiences that his patients share with him that makes his work meaningful. “I’m a storyteller, and I like to listen to stories; I love hearing from people. As I said in my book, I like the life well-lived and I like the stories that people have to say.”

For Dosa, doctors are not merely scientists. A med student who has memorized a textbook but can’t talk to her patients simply cannot do her job fully. Doing the difficult thing and taking the time to learn about your patient is just as much a part of the task of administering care, Dosa stresses. Fostering communication is more than just an enjoyable aspect of his work, however. He believes that spending time reaching out to others to talk and to listen will be the saving grace of geriatrics as a clinically relevant profession in medicine.

Specific elements of the health delivery and financing system that make it unable to properly handle geriatric patients are simply an indication of larger social issues and deficiencies. Dosa believes that the healthcare system is in the process of reorienting itself towards a greater focus on holistic care and patient well being across the board, not just in geriatrics. The 2010 Affordable Care Act (ACA) reform necessitates new healthcare models because science has been demonstrating that the way we currently provide care-the failure to rely on biomarkers to render treatments more precisely, an overreliance on standardized institutional procedures, and silo thinking among physicians, administrators, and other service providers-is not good enough.

Currently, one of the biggest problems Dosa sees in geriatrics is that doctors are paid to perform a specific service, regardless of quality or whether it is even necessary for the patient’s health. Cardiologists order EKGs, radiologists perform scans, and physical therapists conduct physical therapy all because the care delivery system promotes this kind of specialization and pays doctors to provide acute care within their field of expertise-even when it might be better not to.

Patients in end-of-life care situations are disproportionately affected by the current system. “When you ask older folks what it is that they want in terms of their healthcare, they want quality of life,” Dosa says. “They want to be surrounded by family. They want to die at home, surrounded

by family. They obviously want to live a long life and a happy life, but they don’t necessarily want to sacrifice quality for quantity.

“Unfortunately, our healthcare system rewards doing rather than not doing. The system rewards treating rather than not treating, and it doesn’t reward communication. People don’t get paid to communicate, to sit down and ask, ‘What is it that you truly want?’ I think that’s the central dysfunction with our healthcare system today.”

For Dosa, listening is where the care begins, especially with elderly patients where studies suggest that fewer procedures and tests make for a better quality of life.

But taking the time to find out who patients are as individuals is no easy task, in large part because individuals are so, well, individual. It takes time and energy to nuance how one provides care around the different traits and problems of the patient. It’s much easier to treat the symptom without addressing the larger pattern of disorder, and even easier to forget whether this treatment is in line with who the patient is and what they want.

Dosa is adamant that this mindset needs to change. “Older people have multiple medical problems and they have multiple chronic comorbidities, and that requires a different approach. It requires that doctors and healthcare systems speak to each other so that people don’t do things to a patient that are counterproductive just to conform to a guideline.”

Dosa offered the idea of having a “captain of the ship” for patients suffering multiple comorbidities as a solution to this issue. Such a person could manage the nitty-gritty task of making sure the patient’s goals are being met but also making sure that the patient’s multiple physicians are in communication with one another, too.

No longer working in the nursing home facility with his feline companion, Oscar, Dosa sees his role evolving as a teacher of geriatrics for med students and other doctors. When asked what we can do about the relatively few geriatricians compared with the large population of geriatric patients, he responded that the solution is not to do the simple thing by growing the field of geriatric practitioners because, to a certain extent, it’s too late for that.

“It’s more about teaching the cardiologists and the ophthalmologists and the primary care doctors to pay more attention in treating their aged patients and to be geriatric savvy,” says Dosa.

“I view my role, now, as more in a teaching capacity to make sure that the next round of urologists understands what those urological drugs do to patients who perhaps have cognitive impairment, that they are able to manage patients with chronic multiple comorbidities when they do surgery, and that they understand what it is to treat a patient with delirium or dementia.”

Dosa believes that for doctors to have a more comprehensive understanding of their patients requires that they have a more comprehensive understanding-or at least a greater appreciation-for the other branches of medicine. And when doctors are armed with this knowledge, they can focus on their patient’s health holistically, giving them the outcomes they both require and deserve, Dosa says.

These new expectations are not limited to geriatrics, however. Rather, Dosa believes that changing expectations among the population as well as a shifting regulatory environment will drive change. The federal Center for Medicare and Medicaid Services (CMS) is working on healthcare quality measures on which to base reimbursement. This effort is being imitated everywhere in healthcare as a part of a general effort to reduce bloat in an unwieldy system burdened by the recent influx of millions of newly insured patients. The ACA is incentivizing the launch of new accountable care organizations to develop more integrated systems of care. Dosa affirms that though the newly insured may have trouble finding enough doctors at first, this shift away from fee-for-service will be a boon to the country at large.

Lessons for pharma

And where does the pharmaceutical industry fit into this new landscape? Dosa affirms that the industry must be part of this new landscape, though it may have to adapt its business model to do so. As recent studies suggest, drug therapy must be more oriented towards achieving a larger health outcome. Dosa sees clinicians like himself as an under-utilized resource to this end.

“The notion that the physician is no longer the driver of decisions in healthcare has been overstated,” he says. “Closed formulary or not, pharmaceutical companies looking to understand where the gaps are in available treatment options need to work with those on the ground. No one is in a better position to understand what’s needed for the health of patients than the doctors who work with them.”

These new expectations as well as the newly insured population create a variety of opportunities. Many needs are not being met by the current

healthcare system, needs for which many people are willing to pay out of pocket. Dosa hopes that business will step in and embrace this new environment, finding ways to make it economically viable.

“There’s certainly a business opportunity here for an entrepreneur to come into the mix and negotiate with government payers and insurances and help in this situation,” he says.

First forays into this world already exist with some regional HMOs providing compensation to doctors with the money saved by performing preventive medicine, shifting to a so-called fee-for-performance model.

Dosa understands the difficulty that implementation of these ideas presents, however. It involves individuals, companies, and regulators moving away from what is easiest or simplest towards what’s best. Sometimes that means that researchers need to make clinical trials messier and more nuanced. Sometimes that means that physicians will have to make time to pick up the phone and call her patient’s other doctors.

And sometimes that means taking the time just to be there and listen to a patient because there are other and better ways to care for patients than we do currently.

“Doctors are human beings. They have the same hang ups about death and what we can do for patients,” Dosa says. “But we need to acknowledge limitations and decide, through conversation and communication, at what point is being there and letting go more important than providing treatments for specific ailments.”

This sentiment doesn’t have to be limited to doctors, however. Among government regulators, scientists, and pharmaceutical executives, there is room for all of us to do the difficult thing and acknowledge our limitations in order to work with one another to better the way we practice care in this country and the human beings that live in it.

Newsmaker note

Dr. David Dosa received his M.D. from George Washington University in 1998 and his MPH from the University of Pittsburgh in 2003. His book, Making Rounds with Oscar: The Extraordinary Gift of an Ordinary Cat, has sold over 100,000 copies and has been published in 20 languages worldwide. In addition to practicing geriatrics, he has performed research in many areas related to nursing home care, including pain control and pharmacoepidemiology. The recipient of many awards, he recently won a Career Development Award from the Veteran’s Administration to study medication administration in nursing home facilities. Currently, when he is not busy conducting research at Brown University’s Center for Gerontology, he spends time on his latest work, a book of fiction about finding love late in life. Dr. Dosa can be reached at david_dosa@brown.edu    

Cameron Sharp is a contributing writer for Pharm Exec. He can be reached at cdsharp19102@gmail.com