Q&A: Lown Chief on Improving Medicine via 'RightCare'

Healthcare professionals have an "ethical obligation" to provide the right kind of care—not too much, and not too little, says Vikas Saini, MD, president of the Lown Institute.

Not everything done in medicine is based on good, sound evidence, nor is it faithful to what patients and their families truly want. An initiative by the Lown Institute, a nonprofit healthcare think tank based in Brookline, MA, aims to change that.

Lown's RightCare Action Week, October 18 to 24, is viewed as "the start of a marathon," says Vikas Saini, MD, president of the Lown Institute. "We think that the time is right in American healthcare for a social movement that's really an alliance between healthcare professionals and the general public, to talk about the actual quality and experience of care that we all receive."

HealthLeaders Media caught up with Saini by phone ahead of RightCare Action Week to learn more. The transcript below has been lightly edited.

HLM: What is RightCare?

Vikas Saini: The concept of RightCare emerged out of the growing awareness that a lot of what we do in medicine is either not based on good, sound evidence, or is not really truly faithful to what patients and their families really want. It is part of the growing awareness that there is such a thing as too much medicine in certain settings, and is wedded to the notion that more people are aware that it's also possible to not have enough access to medical care.

And so the concept [of] RightCare is really the view that healthcare professionals have an ethical obligation—a really important moral obligation, as well as part of our social mission—to really narrow that variance, narrow the range of the kind of care we provide so that it's…not too much, not too little. Just the right care.

At End of Life, Measure What Patients Value

There's a range of examples that we can talk about, but one of the commonest ones where I think most people understand the idea of too much medicine is end-of-life care, where quite often, patients end up in much more intensive settings of care than they would have wanted.

It's not always easy to predict the future, but anybody who looks at this knows that, systematically, more people die in hospitals and die in acute care settings than they would have wanted. So that's one clear example, I think.

HLM: What's one not-so-clear example?

VS: Well, there are areas in medicine where we don't really know the answer. We don't have the right answer. There are incredible gray zones, and some of it's because the studies that have been done are not as clear cut—[the way that] reality is not as clear cut. And sometimes it's because the situation of a given patient is really hard to plug into the studies that have been published.

So in those settings… there's no slam dunk.It's not easy to say, that was obviously wrong or that was obviously right; you really have to have been there. And that's where we emphasize a really important dimension: It's truly about knowing, for the healthcare professional, to know the patient—their preferences, their values—and to share with them an understanding of both what we know and what we don't know, let's say, what the results of a particular surgery will be, or what the side effects might be, etc.

When we give this message… a lot of healthcare professionals realize is that it's very true. The reason it's so moving to so many people we talk to, is that it feels like it's something we have always said we should do, it's something we have always wanted to do. But for all sorts of reasons it feels like it's harder and harder to have that kind of decision making.

There's too much rush, there's too much pressure around volume and getting patients through door, [there are] so many factors that are at play there.

HLM: How does this movement dovetail with something like the ABIM Foundation's Choosing Wisely campaign?

VS: We started our work at the Lown Institute pretty much the same month that Choosing Wisely came out, and so I'd say we're operating in very parallel tracks. There are two aspects to our approach that are a bit different. One is we're unofficial; were sort of grassroots and in that we're really developing interdisciplinary and inter-professional kinds of conversations that we plan to turn into new ways of looking at these problems.

The other way is that we really think that part of what has to happen to change culture is more about motivation and about gathering large enough groups to influence each other, and to begin to influence the system. [The aim is to] sort of create enough visibility and power for certain point-of-views to be able to help our patients and our communities shape the healthcare system in a way that serves them better.

HLM: If this is what patients and families want, and primarily what physicians want, then what's the pushback?

VS: I'm not aware of a whole lot of pushback on the core ideas. I think the real issue is more that there are a lot of perverse incentives in the system. There's a lot of inertia, there's a paradigm or frame of thinking about things that shapes the culture we've had. And if you add those items all up you get to a place that is what we have today, and…it's not working as well as it should.

And for too many people, it's really not working well at all.

There are individual areas where there's controversy, and so there's no question that when you get down to specific items or specific procedures (like the Choosing Wisely lists of things) when you get to that level of granularity, you always get great debate and you'll always get lots of differing of opinion.

From my point of view that's natural, but it misses the forest for the trees. While any individual issue can be debated, increasingly what isn't debated is that we as a system tend to do a lot of stuff that we really shouldn't be doing.

So it could save a lot of money. It could allow us to do a lot of other things, cover a lot more people, and invest in the other things that really drive health. And managing that transition is really an important goal for all society and should be an important goal for everyone in healthcare, though it does pose challenges for managing the transition smoothly.

HLM: What is RightCare Action Week, what does it aim to accomplish, and how can people take action?

VS: Our idea of RightCare Action Week was that those of us involved in this work and those of us getting involved and interested wanted to raise both the awareness of some of the issues, but also to take an act, take a stand, do it visibly, and do it in a way that would allow us to begin to show other ways of doing things.

And to show both elements of what goes on that could be better—when there's too much medicine, things that could be done differently—but also to show things that represent RightCare that would represent the right care and to show there are better ways for doing things.

We conceived of it as an opportunity to mobilize people around these ideas and to do it in a concrete way. What we found is that there is a lot of interest in the idea. To our surprise, a lot of organizations endorsed us, and endorsed the idea… that includes AMSA, IHI Open School, one of the nursing unions, National Physicians Alliance, National Patient Safety Foundation—a range or organizations.

Here are some of the things that are happening: A group of medical students [and] nursing students in several parts of the country are doing what they call "story slams." They're gathering—kind of like The Moth Radio Hour—they're gathering and [are] going to be telling stories of what they've seen on the ward as a way of sharing, inspiring each other, to begin to offer insight into the process of care.

There is a whole group of chief residents around the country who are going to be doing kind of an "Audubon Bird Count" of the RightCare: going through the week and keeping track or taking notes of what it looks like. It could be an occasion that an opportunity is missed, either to deliver care that was really needed and missed, or not deliver care that probably wasn't necessary.

And again, using the count is a way of learning how to spot these things and begin a process. In the case of those chief residents, they're actually launching with us a program we call RightCare Rounds where they're going to be doing grand rounds and investigating in a case-based way clinical decision making… to tease out how these decisions get made and what drives them.

There's a couple of people who are promoting home visits for people who don't usually do it. [For instance,] there's a neurologist here in Boston who's active at McLean and Mass General who has set aside that day to actually go to the home to somebody who can't get out and to spend a whole lot of time—like an hour, hour-and-a-half—and highlight exactly some of the really important elements of care. [It's] a way of showing that what we need is a system that allows more of that. Not necessarily that everyone makes home visits, but the way in which we relate and interact with patient can really be at a much more deep level than we're able to do these days.

A doctor named Aaron Stupple and I are going to try something experimental: We're going to be going out into the neighborhoods of Boston and setting up a listening booth. It's a little bit whimsical, but it comes out of the idea that too often as docs, we're in the exam room, we're on the ward, and we're really busy with what we're doing, but we never really get an opportunity to share and hear the experiences of healthcare and the system as a whole from our patients or even the general public.

Acute Care Makes Itself at Home

This is an attempt to kind of show that we need more of that. We need more listening from our patients and from our community about how we can change healthcare to improve it. And we're not sure how it'll go, but we think it'll be interesting, and we certainly think we're going to learn a lot. And we're hoping that by doing that we'll hear interesting and important stories. [Maybe] we'll inspire some of our colleagues, and maybe we'll actually create a program that allows us to do that in a more systematic way.

We're going to basically be asking them: What does really good healthcare mean to you? What have you experienced that leads you to that? What would you like to see that you haven't had that you think would make… care that much better?

We're not going to prompt, we're not going to put words in their mouths. But we're hoping that we will get enough insight—obviously we're not going to figure it all out in this—but get enough insight and enough information that there will be some stories that will allow us to think about our own work as we move forward, and design it in a way that we can get much more input on a much larger scale from people.

So as we think about health and healthcare, we're really getting informed by the people who really matter, which is the patients and communities we serve.