Building Health into the Delivery System, Take Two

The following is a guest post from Rushika Fernandopulle, MD, MPP, Co-Founder of Renaissance Health. This is part of a continuing series of blog entries cross-posted here, on the Center for Information Therapy Blog, and the Health Affairs Blog, the conference’s Media Partner in advance of the first-ever “Health 2.0 Meets Information Therapy” Conference in Boston on April 22-23.

Rushika provides another physician perspective on the same question answered by John Halamka this week,
“How do we build Health 2.0 into the delivery system?” Both Rushika and
John will participate in a debate on this topic in Boston.

I am an internist who has been working for the last 5 years to
design, build, and test radically new models of delivering primary care
to improve experience, outcomes, and affordability of care. I currently
serve as Medical Director of one of our redesigned practices in
Atlantic City, NJ.  Yesterday afternoon, Mr. Santos, a 53 year old
Hispanic doorman at a local hotel, came in to see me quite visibly
distraught. His prior primary care doctor had without asking him or
discussing the issue checked a PSA (Prostate Specific Antigen) as part
of his “routine” blood tests and the results were mildly positive
(6.5). He was told, “Your screen for Prostate cancer was positive, you
need to see a urologist right away to have it taken care of.” All he
heard, of course, was “cancer” and “positive” in the same sentence.
Before Mr. Santos had time to even form the first of the dozens of
questions he had, the doctor had already strode out the door. Over the
next few weeks, Mr. Santos went online to read about PSA and prostate
cancer (which yielded over 6 million pages on Google), and started
talking to his friends at work about the issue. What he surmised, quite
correctly, is that the way forward for him was not at all clear, and
that instead of finding answers he only had more (but better)
questions. What really was his chance of having Prostate Cancer? If he
did what really were the benefits of catching it so early? Were the
risks of the biopsies worth this benefit? What were his other choices?

Mr. Santos’s prior PCP clearly operated under the old-school
paternalistic doctor model; I, the doctor, will manage your health;
just leave it up to me. While this works well for some patients in some
situations, for many, including Mr. Santos in this case, it clearly
does not. More of health care than we care to admit lies in the grey
like the PSA issue here, and there is disagreement in the science, and
even more importantly, patients’ values and goals make a real
difference. Also, particularly for chronic conditions, even if we
wanted to we as doctors cannot manage our patients’ health. At most a
patient will spend a few elapsed hours a year with us, leaving over
8750 hours not in our offices, and this is when all the real decisions
need to be made.

The Health 2.0 movement provides a radical alternative to this old
model where the physician monopolizes information and decision-making.
Here patients learn from each other, and help each other make the right
decision for themselves. This has always happened to some extent around
the water cooler and among friends discussing their health problems,
but the web has allowed virtual such communities to form and
conversations to occur, and magnify the potential of such interactions.
This is what Mr Santos turned to after leaving his old PCP’s office.
The problem is that medicine is very variable, and one patient’s
experience may or may not apply to yours. Also there is no rigorous
science filter among voices heard on the web or around the water cooler
and many of the 6.1 million websites indexed by Google give misleading
or even dangerous advice.

Information Therapy,
at its best, is a way to steer a sensible middle course between these
two extremes. It allows a patient to work with a doctor (or other
trusted health professional) to learn from information sources and
other patients, and then filter and process this information with the
application of the best science available to best meet their own goals
and values. A good, experienced clinician has seen many cases of the
same thing, and can help a patient put their information they learn
into perspective.

For our health care system to truly best meet the needs of our
patients, it needs to combine all these approaches depending on the
patient’s wishes and the particular situation. When one is having a
massive MI (heart attack), one simply needs a great doctor to take
charge and reopen the blocked artery. When one is contemplating dietary
changes or creating an exercise regimen, then turning to communities of
like-minded patients (framed broadly as Health 2.0) is an appropriate
approach. However, most of healthcare lies between these extremes, and
Information Therapy, where a trusted clinician helps guide the patient
to the right information and mediates and puts into perspective the
knowledge gained from communities, is likely the right choice for most.

This is what I did with Mr. Santos. We spent 30 minutes together
discussing what he had learned, and perhaps more importantly meshed
this with what his goals and values were in terms of his health. In the
end we decided together to recheck his PSA in 6 months to see whether
it was rising or falling, I pointed him to a number of other resources
to learn more about his choices, and we would decide after this whether
to proceed with a biopsy or not. This process may have taken longer
than what his prior doctor did, but I believe clearly led to a better
outcome for both the patient and the health care system as a whole. We
all deserve no less.

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carelRoger WilliamsMargalit Gur-ArieFL PCPTom Leith Recent comment authors
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In the few short weeks that I have scanned various blogs, I have been able to quickly sift out the insurers, insurance salesmen and IT beneficiaries from the clinicians. There is a clear demarcation between those who wish to care for patients, and those who can only profit from them. Unfortunately the latter are quick to justify their existence, and have fueled Washington lobbyists to the point that the actual caregivers have become lost in the fray.

Roger Williams

The story on this is very well described in:
“Should I be tested for Cancer?” by Gil Welch. See http://www.amazon.com/Should-Be-Tested-Cancer-Maybe/dp/0520239768/ref=sr_1_1?ie=UTF8&s=books&qid=1238956716&sr=8-1
Not necessarily the last word, but an important word!

Margalit Gur-Arie

Let’s assume that Mr. Santos’ PCP really walked out the door after referring the patient to a specialist. I wonder why would a doctor do that? Is it maybe because he had 30 more patients to see on that day and all he can afford is a few minutes with each patient? Why is he seeing so many patients that the quality of care obviously suffers? Probably because PCPs are not getting reimbursed for 30 minutes of care coordination in our procedure driven system. So I would be inclined to give Mr. Santos’ PCP the benefit of the doubt and… Read more »


PSA/DRE is one of the most controversial aspects of medicine. Although I can appreciate the article, this may be an issue that requires much more debate than can be offered here. The gestalt of the theme is not lost, but the example is too divisive to be used as the basis of the blog. In the few short weeks that I have scanned various blogs, I’ve been able to quickly sift out the insurers, insurance salesmen and IT beneficiaries from the clinicians/physicians. There is a clear demarcation between those who wish to care for patients, and those who can only… Read more »

Tom Leith
Tom Leith

MD as HELL writes: > Your post assumes the patient did not already > have a similar discussion with his doctor No, Dr. Fernandopulle does not assume this, he asserts it: “Before Mr. Santos had time to even form the first of the dozens of questions he had, the doctor had already strode out the door.” > If the standard of care in New Jersey is > to biopsy, then he needs a biopsy offered. Why should the standard of care be different in New Jersey versus Manhattan or Montana? > Being in a comfortable herd of people who have… Read more »


Dr. Fernandopulle, Your post assumes the patient did not already have a similar discussion with his doctor, but was afraid and wanted a different answer. As I read your recount, you assume facts not in evidence. There is nothing to suggest that your plan is going to satisfy this patient any better than Dr. X. I bet Mr. Santos left with his PCP thinking he had satisfied him, too. No details of his physical exam are provided, so we don’t know that. No details of his family history are provided, nor are any details of why he went to the… Read more »

Dr.Rick Lippin

Thanks Dr Fernandopulle-
I am very curious. Would your interaction with this patient (Mr Santos) been enhanced,dimmished or unchanged had it been an e-mail or tele-medicine exchange?
Be Well,
Dr. Richard Lippin