OP-ED

Let’s Make Sure “Health” Encompasses “Care”

Risa preferred headshotFor the past several months the Robert Wood Johnson Foundation has been promoting a particular vision– of a Culture of Health in America, where everyone  has the opportunity to live the healthiest life possible, no matter their income, or where they live, or work, or play.

With  that vision in mind, geriatrician Dr. Leslie Kernisan asks an important question in her Oct 7 Health Care Blog post, “Why #CultureofHealth Doesn’t Work For Me.”  She writes: “Is promoting a Culture of Health the same as promoting a Culture of Care? As a front-line clinician, they feel very different to me.”

For physicians treating the chronically ill and patients facing the end of life, good health might seem like a pipe dream. Kernisan and some of her commenters even wonder if the phrase “Culture of Health” could be misconstrued as “blaming the victim.”

I appreciate—and am grateful for– her concern.  I am also a geriatrician, so I understand where Kernisan is coming from. I believe that care and health are two sides of the same coin. Having a system that provides care when, how, and where people need it is a crucial component of a Culture of Health.

I had a light bulb moment early in my career when I realized that we cannot properly care for the very ill unless we address the many issues that affects their health outside the clinic’s walls.  I was doing my residency in Boston when I met a woman I will always think of as “Patient Ruth.” She appeared at my hospital’s admitting station late on a winter night, homeless and helpless, and she brought the cold in with her.

Her feet were swollen; she wore flimsy house shoes and raw leg ulcers made walking painful. Her medical chart was thick; she’d been to the hospital many times before. We did for her what the hospital always did– a few hours in a warm bed, some antibiotics, a decent meal. But the rules dictated that the next morning we had to let her go, limping back to the same problems she had before: No home, no job, lousy food, cast-off clothing, no family or friends to come to her aid.

We were bit players in a system that was not equipped to protect Patient Ruth from the harshness of life outside the hospital, a harshness that was destroying her health and shortening her life. What if, instead of ushering her back into the cold, we could have asked what she needed to keep from having to come back? And then what if we linked her to those people or services? Shouldn’t that be the aim of every medical visit?

Those questions, and the answers, are intrinsic to building a Culture of Health. Ruth is never going to run a marathon, but there are things that can be done to help her find her own “healthy”. Ultimately there is no single way to cultivate health, or offer care. Only by all of us working toward a common goal, for everyone in America — be they sick or well, just born into this world or reaching the end of life — can we truly build a nation where everyone has the opportunity to achieve their optimal health.

Risa Lavizzo-Mourey is the CEO of the Robert Wood Johnson Foundation

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Risa Lavizzo-MoureyseniorenchatChris KapsaPanicAwayChris Langston Recent comment authors
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Risa Lavizzo-Mourey
Guest

Thanks, everyone, for weighing in on this important issue. It is a great reminder of the power of language – and in recognition of the concerns discussed in Leslie Kernisan’s post, and these comments, we’ve made some tweaks to the annual Robert Wood Johnson Foundation message. To make it clearer that a Culture of Health includes everyone in the U.S., be they sick or well, we’ve added the following paragraph: Today most people consider good health and healthy living as activities that are consciously chosen, or something that only those who are already fit can fully achieve. But imagine a… Read more »

Leslie Kernisan, MD MPH
Guest

This is great news, thank you!

I hope you won’t mind if I keep brainstorming memes.

#CultureofBetterHealth

#BetterHealthBetterCare

#CultureofHealth&Care

hm…and of course there is #CultureofCare…

Thank you once again for giving my post such thoughtful consideration.

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Chris Kapsa
Guest

The Culture of Health evolved from the personal responsibility movement of the ’70s. Its antecedents are deeply rooted in our Puritan past. It equates health with moral worthiness and virtue. And illness with moral failings. It is indeed a blame-the-victim mindset. It flourishes in health insurance companies and employer wellness programs. I spent two years as Director of Care Management for a state insurance company. Among other things, I oversaw the wellness programs. The punitive attitudes employees had toward ill or unfit insureds thrived like toxic weeds. It is always “follow the money”. “If a person is ill, it’s his… Read more »

PanicAway
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Chris Langston
Guest

I am very impressed by the degree of passion and engagement being shown in this discussion and by the courage of Dr. Kernisan for having started it. I know how hard it is for former or would be grantees to give feedback to a funder, because at the John A. Hartford Foundation we struggle mightily to elicit even a little bit from our community. I’ll just say that I saved Dr. Kernisan’s piece on THCB to reflect on because it captured so well some of the concerns that I’ve had about The Culture of Health. I am reassured by what… Read more »

Mike Painter
Guest

This conversation has been fantastic. You don’t really need to hear more from various RWJF folks—we can talk about this topic all the livelong day because we’re incredibly passionate about it. We also love to see the passion in these comments—even the criticism and negative ones. It’s truly wonderful. I can’t think of a better conversation for this country to have: what does a Culture of Health mean to you? I’m jumping back into this particular string for one reason: I want to underscore the point that everyone’s views about this Culture of Health matter. Risa’s, Anne’s, Peter’s, Peter’s patient’s,… Read more »

daniel
Guest

I look at a health as a fundamental human service. By promoting health and wellness in all policies we can, over time, shift the disproportionate spending away from disease management to prevention and wellness. No other society in the world spends as much as we do on disease care, and many have better outcomes. It is no longer economically sustainable or rational to continue doing the same and expecting a different result. Without making this shift now we will not only bankrupt the county, but reduce the availability of scarce resources to provide care (of all sorts) to the most… Read more »

Leslie Kernisan, MD MPH
Guest

Anne, thank you for your comment. I think Gilles is getting at something very important. Even if we know that you, and Dr. Lavizzo-Mourney are incorporating a culture of better care into “Culture of Health”, we have to consider how the messaging comes across to the many who just hear the tagline, or even the core RWJF points below: “We believe an American Culture of Health is one in which: 1. Good health flourishes across geographic, demographic and social sectors. 2. Being healthy and staying healthy is valued by our entire society. 3. Individuals and families have the means and… Read more »

Anne Weiss
Guest

This discussion really spoke to me. Not only because I’ve led some of RWJF’s efforts to improve health care quality and value, but as a patient myself, and as the wife, daughter, sister and mother of loved ones who have struggled to navigate the health care system’s troubled waters. Having a system that provides care when, how, and where people need it is a crucial component of a Culture of Health. We’ve got to make the health care system work for all of us. And I do mean all of us, because half of adults in this country have one… Read more »

bird
Guest
bird

Having been a primary care doc for 20 years I understand what you are saying. the problem originates with the payment structure and RUC which is a body of specialists that determine what is important. Right now a 30 year old with a sinus infection pays me the same amount as a 60 yo with diabetes hypertension and poor kidneys. That coupled with fact that a dermatologist will make four times what i make for removing a nonsuspicous mole. The health care system is being forced to give all this special attention to the worried well because they may fill… Read more »

Gilles Frydman
Guest
Gilles Frydman

Anne, you wrote “A Culture of Health, to me, is one that doesn’t distinguish between what goes on inside and outside the walls of the health care system, but gives all of us the chance to live the healthiest possible lives.” RWJF deals with public health issues. What counts is not what one individual thinks, but what populations understand when presented with a term like “Culture of Health”. I think Peter Elias’ patient reaction should be considered seriously and much effort should be done to understand if that’s standard reaction from a significant portion of the population you are trying… Read more »

Leslie Kernisan, MD MPH
Guest

Anne, forgot to mention this in my comment below:

THANK YOU for mentioning the need to care for health care providers…so important as we are part of the population at large and especially because we can’t help people very well when we ourselves are burned out.

bird
Guest
bird

let the ill go ahead and die they are a drain on the system, and might as well kill off those born with any sort of genetic defect they will only cost us more money as well, and lets see if we can produce a genetically pure race that has no illness as well ie margarat sanger and adolf hitler

Perry
Guest
Perry

Face it folks, the healthy do not need the medical system.

@BobbyGvegas
Guest

Assuming they do not get involved in accidents. BLS reports ~3 million employment-related accidents per year alone, 95% of them non-fatal. Add to that non-workplace related, you still have a lot of need for a medical system.

Perry
Guest
Perry

I understand Bobby, I take care of some of those work-related accidents. We do need a medical system for the sick and injured. We just need to focus the resources in the right place.

pcb
Guest
pcb

yep. but there’s a lot of money to be made convincing them otherwise

Peter Elias
Guest

I was referring to the 2014 President’s message here: http://www.rwjf.org/en/about-rwjf/annual-reports/presidents-message-2014.html It talks about being and staying healthy, but doesn’t speak to the people who are ill and struggle for even some improvement in health, let alone those who just want dignity and comfort because health is no longer an option for them. I think I understand the intent: a society that values the things that foster health. But the message I hear (and my patient heard) is that health is not just the goal, but the only acceptable state. That’s pretty hard on the ill. It lends itself to a… Read more »

Peter Elias
Guest

I read the piece on the RWJF site with considerable dismay. While the goal of a society committed to equal opportunity for health is unassailable, the language of the essay is exclusionary. Seriously and hurtfully so. The vision has no room for people who are ill. I showed it to a patient today: mid-30s, never-smoker, former endurance athlete, now struggling with chronic medical problems resulting from peri-operative complications from a repeat c-section. Her description: it’s like giving a short, obese person of color a brochure for a summer camp with pictures of tall, thin, Nordic athletes. Looks nice, but I… Read more »

Leslie Kernisan, MD MPH
Guest

Peter, not sure just what you read on RWJF site, but that is quite a response from your patient!

What do you think of “Culture of Better Health?” (I’d love to have “caring” in there too, but trying to stay concise.)

I feel like no matter what a person’s health situation, they and others can help make it better…for ex hospice improves the health of dying people, because it improves their wellbeing and their family’s wellbeing, and wellbeing is a core part of health. Walkable neighborhoods help make health better for people who are obese and have diabetes. And so forth…

@BobbyGvegas
Guest

“I had a light bulb moment early in my career when I realized that we cannot properly care for the very ill unless we address the many issues that affects their health outside the clinic’s walls.” __ ~90% of health/wellness originates in the myriad (and frequently overlapping) “upstream” headwaters. I write about that a lot on my KHIT blog. BTW, I’m the one who aired the “Blaming the Victim” concern. See my post about the “Rescue-Victim-Persecutor triangle.” http://bgladd.blogspot.com/2012/04/socioeconomic-drama.html Politically, the U.S. has gotten pretty deep into the “Persecutor” phase across a variety of fronts in recent years. The ostensible “failures”… Read more »

Leslie Kernisan, MD MPH
Guest

Dr. Lavizzo-Mourney, Thank you for taking the time to read my post and to write this thoughtful response. Clearly we want the same type of care for people once they are unwell: care that is caring, comprehensive, coordinated, addresses the Unmentionables, leverages other disciplines and the power of communities, addresses the wellbeing of the family unit, is in line with the person’s preferences and goals, and so forth. We even have bright spots of this care, in certain primary care medical homes, and hopefully we’ll see access to this care increase soon. Yes we can frame this as promoting health.… Read more »