Paint by Numbers Article Swipe

With recent articles and an editorial, the Journal of the American Geriatrics Society has taken the initiative to propose a revision in the way medical care is provided to older adults with multimorbidity to provide an increased focus on patient-centered care (PCC).1-4 We encourage further submissions on this topic, particularly clinical investigation studies. In this article, we assert that the complexity of our current menu-driven care for older persons with multimorbidity can undermine PCC and must be revised. We state that we must shift from our current reimbursement-driven system with an exclusive focus on physician management of specific disease to a system driven more by patient preferences with a comprehensive view of the totality of care. This is especially important in hospital care. In recent decades, enormous progress has been made in the care of older persons, including those with multimorbidity. Patients with major acute and chronic medical disorders, who might not have lived previously, now routinely survive. Medical science and subspecialty medicine now drive care that enables most medically complex older patients to live longer than would have been expected a few decades ago, but this progress has created questions about the process of care. Our view is that care of older persons has become too menu driven, based on lists of medical problems, with insufficient attention to patient goals regarding function and quality of life and the inherent tradeoffs in complex care.5, 6 The current piecemeal approach to care of complex multimorbidity can result in iatrogenic complications, excessive testing, and high-technology interventions, plus patient and family confusion. Although improvements have been made in tracking clinical detail and in linking medical records across sites of care, our current arcane computerized medical records exacerbate work complexity and take time and focus away from detailed interactions with patients. Our rapid growth in sophistication has been accompanied by ever-greater subspecialization and fragmentation, particularly in complex older patients. To feel competent to master the ballooning detail in each subspecialty, we tend to split areas of clinical focus into ever-smaller fields of endeavor. As inpatient attending physicians today, we frequently wonder who is looking at the overall big picture. In years past, this was the responsibility of the patient's primary physician and the hospital ward team. These days, all care is compressed in time and space, which drives the internal medicine team to become scribes and servants for subspecialty experts who themselves have an increasingly narrow focus. The speed of this fragmented care is driven by our anachronistic reimbursement system, which rewards technology and interventions over personal care and a focus on functional status.6 With this growing fragmentation and narrowing of focus, we are now reminded of an activity from our youth: "paint by numbers." As children, paint by numbers allowed us to follow a simplistic coloring format and create an image of the subject desired. The goal was to provide a template for potential artists to create a recognizable image. However, these images were lifeless and flat, and they failed to evoke any larger understanding or insight on the part of the viewer. On today's hospital internal medicine wards, the combination of time pressures and volume incentives forces most of us to rely on simple menus and specialty recommendations as the primary drivers of our clinical decisions. We see vanishingly little evidence that guidelines and subspecialty opinions are applied after thoughtful deliberation of the complexities and tradeoffs of caring for older persons with multiple chronic disorders. Deliberation regarding care delivery for the individual patient has been replaced by a paint by numbers approach. We often see younger consultants relying primarily on their mobile telephones to get the right "recipe" of recommendations for a given older patient. Often, such consultants have much of the note written based on the chart and a report template before they ever see the individual patient. In times past, attending rounds would be the time when perspective and thoughtful deliberation could be applied, important for nuanced care and for role modeling how the seasoned attending artist can go beyond an initial paint by numbers approach. Now, we usually see regurgitation by both learners and faculty of a menu of standard recommendations focused only on a specific organ system. Little time is allowed for reflection and consideration of individual patient preferences or differences. We believe that this system of care has perverse effects on the training of new physicians and nurses. Our current paint by numbers system does not provide learners with a perspective on comprehensive or well-integrated care. In most hospitals today, physicians spend surprisingly little time examining and talking with patients or their families.7 House staff spend most of their time in computer rooms, in part to draft notes to facilitate faculty third-party billing. For expediency, rounds are frequently conducted in these same computer rooms and notes may be typed during these "rounds." It is often not clear who has examined and discussed goals with the patient. In these settings, care plans are usually devised without patient or family input. At most, the house staff tend to report back to the patient and (occasionally) family what the care plan will be, with little input or discussion of goals and preferences. These rounds then take on a "flat dimension" devoid of humanity. It seems to us that our paint by numbers approach is driving out all nuanced thinking and personalized care. It appears easier to order a large battery of menu-driven tests and procedures than to think carefully about what is really needed. It is time to reengineer our approach to hospital care of older persons with multiple conditions. The "Age Friendly Health System Initiative" described previously in this journal can help guide us.8, 9 We have several additional recommendations that address the specific concerns detailed in this article. First, hospital team rounds and deliberations should be conducted in the older patient's and family's presence when possible. To conduct team rounds (primarily) in a conference room distant from actual patients is a recipe for divorcing care decisions from individual patient reality or preferences. Second, we need to revise our method of reporting and discussing cases. We should insist that our written and verbal presentations of cases always put more emphasis on consideration of the impact of our plans on patient preferences and function. Far too often, our case write-ups and presentations contain a simple laundry list of major problems at the end. There is little effort to put the larger "picture" together in terms of the tradeoffs or impact, especially when there is multimorbidity. Third, our medical record systems must be improved for the care of older persons with multimorbidity. Currently, the criteria these systems use to enable billing greater charges are a classic example of paint by numbers. This system of copy and paste of endless (often minor) disease-specific detail results in bloated notes that are not meaningful for the essence of care and distracts the physician from time with the patient and thinking about the larger picture. Fourth, we need to spend more time focused on the emotional impact of disease on patient and family well-being. Many times, our care and rounds seem devoid of attention to the suffering that patients and families are experiencing, as if the paint by numbers set did not include a number set for suffering. Family and support systems are largely ignored in our menus for care, they but are absolutely critical and probably more important than our physician deliberations. The approach described herein goes well beyond paint by numbers and allows the healthcare team to depict and manage a broader in-depth reality for older persons who are ill. This broader reality will elevate our vision far beyond the flat images previously "painted." The authors appreciate the excellent editorial work that Dr. Joseph Ouslander and Ms. Laura Hayworth contributed to this article. The authors have no conflicts of interest to report. Conception: W.B. Applegate, K.P. Ober, B. Upadhya. Drafting of the manuscript: W.B. Applegate, K.P. Ober. Revising the manuscript: W.B. Applegate. Approval: W.B. Applegate, K.P. Ober, B. Upadhya. The American Geriatrics Society supports the Journal of the American Geriatrics Society.