Essays

Barrier Language

Words are incredibly powerful. So few symbols can evoke such deep feelings and rouse such great emotion – I have a dream. Language is the great achievement of who we are. But while you, I, and everyone else employ the same words to communicate shared ideas, what those words mean precisely to each of us among the many views and opinions that make us unique individuals can be quite different.

What if the language that we use in healthcare creates a bias, and produces real impact in how we help sick people? Would fixing the language to erase that bias become the cheapest and easiest improvement imaginable?

I know there are phrases that I interpret, mistakenly, as shorthand for more complex ideas. And I think there are some bigger examples that affect all of us more than we might believe.

One troublesome word is noncompliant. If a patient has been labeled noncompliant, he must not really want to get better. I can belabor the same points ad nauseam, it will not mater. This is of course an unfair mischaracterization of any individual. But we’ve all heard it, and we’ve all said it, and we’ve all thought something like this before.

Because we’re motivated to do the most good for our patients but also limited in time and resources, we make a subconscious, egalitarian decision to invest a little less into the care of this patient – we know we can do plenty for the patients who want to get better, so we should focus more on them, to maximize our own impact.

We should erase noncompliance from our collective vocabulary – not in the name of sensitivity, but because using it allows us to circumvent the real issue. When we accept a patient’s noncompliance, we have failed to address the root cause of his disagreement with or inability to follow our recommendations.

Another that gets me is telemedicine. I know that technology will change healthcare. Still, when I hear about a telemedicine consult, I picture a clunky and ineffective process that can’t possibly be as good as a provider’s real presence. I am of course wrong here as well: these tools are validated and help expand the reach of specialist providers.

I don’t know where I developed this bias, just that it’s there and that it’s not unique. I wonder how I would feel if my family member were evaluated, say, through a screen by a teleneurologist in the ER, who has the final say on whether or not to give tPA. I think I’d rather hear that they’d be evaluated by a neurologist, and that the best one available was remote. I realize also that this is irrational.

But these are small fries. There are bigger distinctions to make, and they are not semantic.

When do patients become patients, and when do they revert back to being just people? Aren’t they people all along? Is an individual with a chronic illness still a patient between care episodes? If I’m not sick, do I become a patient when I go for a physical? What about a person on the threshold of a diagnosis? A man warehoused in a nursing home for social reasons?

We should erase the notion of being a patient altogether, and talk only about people. This could change how and when we engage with people – each other – and facilitate a more proactive culture of wellness. It might change ideas about responsibility for health decisions. It would absolutely change our biases about where people need to be when they’re engaged with health services.

But for that matter, what is healthcare? Is it a label for any interaction aimed at improving someone’s well-being? Is it limited to exchanges between sick people and licensed professionals? Is it the sum of services provided within the walls of the healthcare system? (And haven’t we created those ourselves by defining what insurance pays for?) What about services done in a hospital, by a provider, paid for by insurance, that aren’t necessary in the first place?

When we talk about the healthcare system, we all more or less mean the sum of experiences between patients and providers, in hospitals, clinics, or other designated settings, involving services which are intermediated by insurers. And there are some colossal problems to unpack here.

Imagine that a patient, at her yearly physical, has no complaint beyond that she feels out of shape. On paper, she may not meet the criteria for any diagnosis. Many providers can help her now, and can do much more for her today than they can a year from now, but they won’t be doing healthcare – at least not in the way we’ve allowed it to be defined by codes and payers. Maybe what this patient means is that she feels the symptoms of early insulin resistance, that she’s at risk for and on the precipice of developing diabetes, but it’s not her job to know or tell us that: it’s our job to tell her and to do something about it.

Insurance won’t pay for healthy food or exercise education, and that means care of that type happens outside of the healthcare system. The existence of codes attached to diagnoses on paper literally stops us from doing the right things to care for this person. Paradoxically, a system which is supposed to enable care is now preventing it.

There are too many individuals at home right now deteriorating in functional capacity who we will not know about until they fall and become patients. Even if we could identify them today and engage with them before injury, thereby preventing a massive and costly sequence that shortens lifespan and creates lasting limitation, we wouldn’t be doing healthcare as it stands.

Would we be providing care to people who need it, at the right time, and in a way that could impact them more than anything we might do after the fact? Absolutely – but not in a way that the healthcare system is designed to operate (i.e. receive payment for).

If we started from scratch today and redesigned the delivery of health care, we would never build what we have now. We would never use the words that we do because we would never arrive at these inverted concepts. We might not build a healthcare system at all, but instead engage with people proactively, at home. Instead of paying for procedures and hospitalizations, we would create a population budget like we do for education. The important thing is that we wouldn’t impose the barriers that exist now, and we wouldn’t think of people as needing our help only after they become sick and can be called patients.

Nothing became this way on purpose. We evolved to where we stand through dynamic societal pressures and adapted to succeed in relation to the payment models presented to us. The language that we use, which has meaning only in this context, connotes very real bias that influences health decisions enormously. We won’t ever stop calling people patients or talking about the healthcare system, but we should be mindful of the ideas attached to those words, and always question whether the choices we make might be different if we could erase those preconceptions.

 

 

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Blog, Essays

An Epidemic of Isolation

More than two thirds of Americans use social media, and 90% of adults in the US have a cell phone. With these tools surrounding us, we must be more connected with one another than ever before. Right?

It doesn’t feel like we are. At least, the people who engage with the healthcare system don’t feel connected to the rest of us. They feel lonely. It feels like we send them off into situations in which we know they’re not equipped to succeed; that at the intersection of the healthcare system and the rest of society altogether, we’re doing just what we talk so much about within clinical practice – siloing off from each other.

The healthcare system has no pill or procedure for this problem. We should not mask its symptoms. Nursing facilities are the furthest things from the answer. Home care visits, while important, serve other purposes.

Our society, at least on any meaningful scale, has not reorganized to meet the needs of its isolated elderly. So many could be helped more than anything by simple contact, yet we engage with them only during sickness episodes. We haven’t reorganized to address a group who we’ve done well enough caring for to keep alive but not nearly well enough for to keep safe, active, or engaged once they can no longer live alone.

We wonder at the patient who returns to the hospital time and again. We tell each other “he’ll be back,” when we discharge the man with the wound on the sole of his foot, the history of substance abuse, who cannot afford his medicines, has no family or support, who has not worked in years – as though the hole he finds himself in is one that could be escaped from through hard work or determination. We erect boundaries around what constitutes hospital care and where personal responsibility begins, then ignore the massive unclaimed territory between them – the vast expanse that exists between what we’re designed to offer and what patients really need.

Evidence-based healthcare long ago surpassed the biomedical model. It’s well-established that health and disease are influenced to a great degree by psychosocial factors. We know that social stress – an emotional experience – can stimulate a range of harmful physical changes. The mechanisms are complex: chronic stress (of any cause, loneliness, poverty, or otherwise) leads to a sustained increase of sympathetic nervous activity, which drives expression of genes and production of cells that promote inflammatory changes and generates high blood pressure and hardening of the arteries.

And causal or not, a relationship exists between social isolation and behaviors like physical inactivity and poor diet; choices that also elevate risk for nearly every kind of disease. We don’t need any more literature to understand this. We observe over and over the positive-feedback loop of sickness and social withdrawal.

This has become a characteristic deficiency of the system of healthcare delivery in the United States. The people we are tasked to care for come to us problems we understand. Their solutions are not always straightforward, but the barriers to their implementation we ourselves have created.

Because there is no money to be made in solving these problems under the current structure of reimbursement for services, we go instead through the motions of administering treatments that we know will not be effective until the more fundamental problems underlying the disease are addressed.

Our patients return, worse off than they were, and we tell ourselves that burnout is a product of work volume rather than our own powerlessness to help the people in front of us.

We have the resources to solve these problems, and in fact, they might present their own solution. We need only to make the first move, without expectation of reward.

There are many retirees armed with the willingness to help, and there will only be more. There are many extant models we could emulate: consider how we assign jury duty and how we perpetuate social security. We need to care enough to coordinate what we have with what patients need. If we do well, we can leverage the financial benefit to the system to influence change.

This is a situation where everyone involved can win. In fact, the only lasting solution to this problem will be the one which benefits every group aiming to keep patients healthy rather than treat them after they’re sick.

The people who spend so much time as patients, because our system has no good solution otherwise, would experience enormous benefits of reduced mortality and morbidity: they would add years to their lives and life to their years. They could escape the cycle of being hospitalized, warehoused in facilities, and teetering on the edge of safety at home for brief periods between sickness episodes. They could, themselves, find renewed purpose in checking on elderly neighbors and supporting peers.

Our system, starved for common-sense solutions that cost a little and accomplish a lot, could save enormous sums for doing something better than what it’s doing right now. And providers could do work that might deliver the impact it’s supposed to. We all benefit from the power of cumulative purposefulness.

Social wellness visits will not ever produce billing revenue. That’s not a problem of the idea, but of our strange collective viewpoint about the purpose of healthcare services. Always, to advocate for good programs sooner-or-later demands a willingness to reduce their value to cost-modeling. If we view hospitalization for chronic illness as a failure on the part not just of outpatient services but of community itself, it’s easy to see why proactive wellness visits could be cost-effective. Keeping patients out of the hospital is a cost-saver for the system. It’s a benefit to taxpayers. It preserves access for the very sick.

There is only one focus which will lead to sustainable change in our system. We need to do the things that keep people healthy, that are good for them before they become patients.

Deficits of social connection may not fit into DRG buckets or under the ownership of one group. This should not limit us from addressing them. We can help people in meaningful ways by choosing to put their needs and the long-term health of our system before the rules that we have in place now.

 

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Blog, Essays

Ownership

In healthcare, we enjoy unequaled opportunity to create special relationships with our work. Few enter caring professions for practical reasons alone, and fewer still survive rigorous training without sincere belief in what they might accomplish. And cliched though they may be, the many mission statements which purport the ‘art of caring’ or similar ideas do convey something real and meaningful.

But, to even the naïve, enough time spent around healthcare forces a certain perspective. A machinelike structure becomes difficult to overlookone engineered to squeeze out dedication and compassion in favor of the calculated administration of services.

There are new deficiencies in this system all the time, and the old ones remain. Compassion, after all, produces no billable service units. And as businesspeople hand down goals, facilities focused on shorter-term success (which many must become to remain competitive in a climate of acquisition) game those metrics by reorganizing the ways they care for sick people. Providers feel powerless to contend with the increasingly conglomerate system that surrounds them.

And they’re not totally wrong. But part of this is providers’ responsibility: we’ve relinquished ownership of this system and it’s direction. This barely-recognizable behemoth mutated to serve interests well beyond health itself leaves us struggling to empower our patients to effect meaningful change, searching for the time to get at the real roots of their maladies, and battling to do work that we can proudly sign our names to, the work that we imagined we might be doing.

A craftsman maintains a direct and personal relationship to his work, and the quality of his product is supreme, unthreatened by assembly lines. But in this iteration of healthcare, providers are not craftsmen. Care is fragmented. Each provider must focus on what he can be reimbursed for, regardless of the scope of his training and of what might help his patient most.

In the name of cost-efficiency, the most relational work there could be feels increasingly dispassionate and impersonal. Providers are shortchanged on the privilege to help the person in front of them. Clinics are engineered to maximize profitability and score highly on metrics that distract from real quality of care.

The deleterious effect of this focus on the wrong goals is not easily overstated. Productivity, not quality, has become the chief measure of a provider’s worth, and it should be no surprise in that paradigm when some quickly refill opioid scripts instead of beginning a long and difficult process which they don’t have time (and insurers won’t pay) for.

It should be no surprise either when patients, who walk into our clinics from a culture of rampant consumerism, view their bodies as products and demand effortless solutions to their complaints. They, like providers, feel powerless to contend with the system around them. Individuals perceive such limited capacity to impact their own health. Instead of empowering them to overcome that view, we perpetuate it through our own compulsive focus on customer satisfaction and passive engagement.

But insurers pay for office visits, for procedures, for medicinesnot for healthy food, for being active, or to quit smoking. This is the proximate cause of care provision different than what is best for patients, and it exists because of the cultivated dependency on reimbursement dollars faced by hospitals and clinics today.

Engaged patients who take ownership of their health aren’t just much cheaper to take care of, they’re rewarded with longer lives of higher quality. But a hospital makes more money from a patient who hands over ownership of his health in favor of the passive procedures which cost many times more than effortful but efficacious alternatives. Behavior change, the highest-value focus there could be in terms of outcomes produced relative to their cost, is paradoxically one that will never generate a dollar of revenue for a hospital system, and that has relegated it to the lowest tier of importance.

Problems like these are pervasive in a self-defeating complex that undermines providers’ opportunities to effect change by overwhelming them with patients, dictating what types of care can happen and when, and producing incentives that clash with right practice. While these decisions might benefit the balance sheet of one facility, to our patients, providers, and system altogether, they are deadly.

If we wrote an equation to predict burnout, we might divide the total impact of the work we do by its volume. Right now, everywhere, volume is too high and opportunity for impact far too low. To fragment care as though it occurs on an assembly line takes away not just the responsibility but the satisfaction of and sense of ownership to help people, replacing them with feelings that we are partitioned from one another and must not deviate focus from our assigned tasks, must abandon the ideas of care and person in gestalt. It produces a system of technicians and obfuscates responsibility.

As quality slips in a system that pressures services different from the things that patients need most, providers’ effectiveness is limited by a kind of inaction on our own part. We consign ourselves to do our best within the system as it is and accept that its faults are too large and complicated to erase. But this system exists to enable people who take care of patients, not to direct us.

The privilege to help take care of people demands commitment. Clinicians, even very good ones, who complete visits, bill units, and consider a day’s work finished, are enablers of this system. The providers who will solve these problems will be those who, beyond their clinical responsibilities, engage with the rules of a damaged system and change those rules to support what is right and sustainable for patients.

The myth of healthcare is that altruism is exclusive from competitiveness. The hospital that will thrive in tomorrow’s healthcare is the one that identifies synergies between things as they are now and things as they should be, dedicates resources to those areas of overlap, and works towards reorganizing the system around it to better serve patients.

The fragmented nature of care produced by fixation not on ownership of good work but instead on compliance with orders and rules is far-reaching. It influences quality, cost, and satisfaction to a great degree. And it’s backwards: the system exists to support providers and patients, not to direct them. We’re right now more focused on administering services than empowering patients to achieve actual health, because services, not wellness, are what generate revenue. But the goals of all parties can and should be aligned.

We have in healthcare an incredible advantage, and one that will help us through a time where another industry might flounder: people are drawn to this line of work by sense of internal purpose, sincere and unwavering. We all share in the responsibility to change the rules of this system to enable what we know is right, and it will be providersnot administrators or policymakersthat solve these problems.

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Essays

Gun Violence and Public Health

Less than one year ago, on an early fall evening in Las Vegas, 59 people were killed at the outdoor Harvest music festival. A single shooter injured hundreds more, using firearms purchased through lawful channels.

There have been many mass shootings in our country, before and since, and in 2015, deaths from gun violence eclipsed for the first time deaths from motor vehicle accidents.

Not long after Las Vegas, discussion emerged in professional journals and from other media about the examination of gun violence as a public health issue. Regardless of belief about root cause, it is a fact that incidence of injury can be reduced through limitation of exposure, guns or otherwise. It is a fact that a highly-visible tragedy like a shooting can become a more effective stimulus for change than can the cumulative effects on millions of a more insidious affliction, like mental illness.

Most gun deaths are suicides. In 2015, of 36,252 Americans killed by guns, more than 22,000 fatal injuries were self-inflicted. Whether or not it makes sense to count these together with murders, this is more than suggestive of a mental health crisis – it is shouting of one.

To control mental health care (and not guns) is a favored strategy of the National Rifle Association. It’s unfortunate that a lobbying organization so powerful in its influence on policy would obfuscate real solutions and perpetuate a damaged system that enables almost 100 deaths every day. The need for change is emergent, the evidence beyond excessive.

While incidence of gun-related deaths can be limited by control of access to firearms, access to a gun does not cause a healthy person to carry out a shooting. It doesn’t do so in other countries, it doesn’t do so here. The central problems are larger and more complex.

Mental health care is deficient. Access to the right services is poor. Cultural and socio-economic pressures contribute to the epidemic. Is it possible that instances of gun violence (and perhaps of substance abuse and many other behaviors) are societal expressions of cultural deterioration?

If not deterioration, what is the right word to describe the accelerating wheel of work and consumerism? Would art and entertainment in a deteriorating culture grow increasingly escapist, selling reprieves from reality through superhero movies and fantasy sports? Would ads, crammed onto everything and most effective when they can convince audiences of a problem solved only by their product, be inescapable in that culture? Might families, even while sitting at the dinner table together, become so enthralled in peers’ highlight reels and cling to the instant gratification of likes, comments and shares?

Easy access to guns may be a problem, but it is not the problem. We can view and discuss guns as a public health crisis, but the label has little meaning beyond the amount that it might affect public funding for research. Smoking and obesity are without question crises of public health: they and their associated illnesses subtract both quality and quantity from a person’s life on an unmatched scale. Guns take quantity, and they do so in an abrupt and visible fashion. Mental illness takes quality, in a way that’s hard to measure and understand.

The idiom that fits here is that we’re trying to avoid throwing the baby out with the bathwater – trying to protect against sacrificing something important that might become lost in a sweeping change. The irony is palpable, because as our system refuses to act on the issue, we are allowing kids to be killed in schools.

Limiting access to guns may not be the best solution to the present crisis. But it will effect change quickly. The best fix, the one that addresses the real problems, will be slow and challenging. We shouldn’t lose sight of improving mental health care. But the best fix isn’t fast enough, and we are past the point of wondering whether change is warranted.

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Essays

An Open Letter to APTA CEO Justin Moore

Dr. Moore,

Although a stated legislative priority of the APTA and despite meaningful advocacy, Medicare’s reimbursement cap for rehabilitation services has gone into effect with the new year. This will, as you’ve pointed out, present a barrier to delivering impactful care to older adults. Although our arguments are straightforward, asking congress not to limit reimbursement might become easier if our profession could better demonstrate the value of the work that we do.

As reimbursement for many services shifts towards a bundled payment for each care episode, physical therapy’s value to health systems will grow. PTs help patients achieve good outcomes at significantly lower cost and with less risk than surgeries and opioids, which will further establish PTs as integral providers to systems competing to provide quality, cost-effective care. In the face of systemic payment reform, this is the time to show how much we can contribute to a healthcare system in need of cheap and effective intervention.

As fee-for-service fades and organizational incentives shift away from maximizing revenues with high-cost procedures towards instead keeping costs of care low with conservative treatments that achieve the same outcomes, physical therapist referrals could become ubiquitous for hospitalized older adults, for outpatients with chronic pain, and for preventative wellness.

Our profession and the ideas that it represents are fundamentally aligned with the needs of our healthcare system. Prevention is not just less expensive than treating disease – pain, diabetes or arthritis – after it’s progressed; it’s a better strategy for minimizing the impact those conditions have on quality of life. The active engagement of PT treatment stimulates change that is more productive and sustainable than a passive, procedure-oriented approach.

A shift towards bundled payments and value-based care presents an opportunity to demonstrate that low-cost, conservative treatments should not be viewed as ancillary because of their low revenue, but instead as central pieces of healthcare for the very same reasons that they are relegated to a lower tier of importance under fee-for-service.

Capturing the value of rehab intervention is complicated, but the problems we can help solve are equally so. Opportunities for improvement that benefit patients, health systems and insurers at the same time are unusual, but we have a clear one. While repeal of Medicare’s therapy cap is a worthwhile goal, my belief as a PT is that demonstrating the value which rehab services offer to health systems should be our highest priority in anticipation of payment reform.

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Essays

Physical Therapy & Value-Based Care

In healthcare, there are many instances of great value. An excellent nurse, a dedicated primary-care, a skilled physical therapist, or any other provider can all deliver strong return on investment. But value has come to mean something different than helping patients achieve the best outcomes: our system right now prioritizes (and has become very effective at) finding opportunities for clinicians to bill lots of service units, and the cost has been fewer chances to genuinely impact those they serve.

It’s crucial that PTs understand the concept of value in healthcare and that our peers know what we can do. All of our roles are evolving in a system which is itself far from static, and while the scope of what PTs offer relative to what they cost is favorable by a wide margin, utilization can be improved.

We have some strong and timely factors on our side. Prevention is less expensive than treating disease, from pain to obesity, after it’s progressed. Conservative intervention is more sustainable and accompanied by fewer consequences than invasive treatment. Recent changes in academic training mean that PTs bring meaningful expertise at low cost relative to skill.

Any year’s CDC data for chronic disease incidence make a case that prevention has been so far unsuccessful. We run the risk of payers misinterpreting prevention as cost-ineffective, but they should instead see an opportunity to expand the roles of providers who are well-trained in conservative interventions. With a massive and costly burden of diseases amenable to lifestyle change, if the real goal of our healthcare system is to improve the wellness of the people who interact with it, it makes sense to encourage the things we know they need.

The fee-for-service model’s emphasis on passive involvement from patients is a major source of healthcare’s trouble: come in with a complaint, receive some treatment, repeat. Providers don’t set out to enable poor decision making, but contend with culturally ingrained demands for quick-fixes that trivialize effort and accountability, and sometimes face pressures themselves to solve problems in certain ways.

Because of fee-for-service, our system has relegated cheap, conservative treatments which help the whole person to a lower tier of importance. This is a mistake, and a legitimate criticism of the business-like organization of healthcare. PT and lifestyle intervention can produce great impact at low cost, but are not reimbursed like surgeries or hospitalizations. Low cost should be the major strength of PT, but when hospital systems need to maximize revenue to stay competitive, a strength becomes a barrier.

One great appeal of rehab medicine is how different it can be from other healthcare services. Patients’ outcomes depend more directly on their effort; they can see and feel progress if they’re engaged and won’t improve if they expect a passive relationship with their own health. Just as we expect active involvement from our patients, we owe to our system active demonstration of the value we can add to it, particularly in the care of patients with chronic disease.

The scope of physical therapist practice has expanded immensely and PTs are a bargain right now, but patients, providers and insurers don’t always know it. For payers, this should be seen as a market inefficiency and a case for greater utilization. One demonstrative example is the widely variable management of back pain: a patient with a herniated disc might end up at their PCP’s office, with a physical therapist, with a neurosurgeon, in a pain clinic, or somewhere outside of the healthcare system entirely.

Despite no shortage of data illustrating the best course of evaluation and treatment, this haphazard process continues. For example, in many cases of back pain there is no indication for costly and invasive spinal surgery over PT intervention. But surgery is passive, which appeals to some patients. And hospitals are reimbursed huge sums for those procedures, which appeals to those whose focus is the financial statement.

The problem is not lack of knowledge, it’s absence of incentive to choose the best thing for the patient and the best thing for the entire system of healthcare financing. Under a value-based payment structure, this will change.

There are so many instances beyond outpatient orthopedic care where PTs can deliver great impact: early intervention in the ICU, assisting in the diagnosis of a movement disorder before functional limitation, outreach programs to help maintain independence or engage with patients affected by chronic disease.

We need to continue to demonstrate our cost-effectiveness, but also to position ourselves to implement these high-value programs. We have few barriers to streamlining referrals for diagnoses that are already understood as PT appropriate, like back pain. We should advocate for prevention initiatives focused on the chronic conditions where lifestyle modification can be highly cost-effective. We can participate in policy change and model best practice in terms not only of patient outcomes, but of value to a healthcare system that is starved for it.

PTs won’t solve healthcare problems alone, but are positioned to contribute meaningfully to the solutions this system needs. We have some responsibility to advocate for greater involvement in areas where we can better help patients than more costly alternatives. We need to refocus our advocacy efforts towards better understanding of what we do and how impactful it can be for patients relative to what it costs. If we don’t, we repeat a problem already too common in healthcare: addressing symptoms, like Medicare’s therapy cap, rather than meet them at their source.

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Essays

Value in Mental Health Screening

The duality between mental and physical health is artificial, and something that we’ve manufactured. We know that mental state and internal physiology influence one another and that social factors affect disease risk more powerfully than genetic ones. Still, as a healthcare system we perpetuate a culture of division and limit our capacity to help people because of our inability to categorize them neatly.

There are so many individuals with unmet mental health needs in our communities: the few with severe illness we can see and get to and sometimes fix, the many with less severe conditions we don’t know always how to reach. There’s the complex relationship between homelessness, mental illness, drug abuse, and crime. We invest in huge prison populations and now in treatment programs too, but less than ever on affecting the pathologies at the root of those problems. We are only as good as the care we take of our most vulnerable, and we are failing those least capable of calling attention to the fact.

It’s understood that prevention is a cost-effective strategy for dealing with many types of illness, but it’s seldom discussed in the context of mental health. Like the annual physical or six-month cleaning at the dentist, there must be some value in a periodic screening or at least some amount of contact with a mental health professional for those at greatest risk. A worsening physical illness – back pain, pneumonia – becomes more difficult for a patient to ignore. A worsening mental illness can leave patients less likely or able to seek out help, which is reason to treat it differently than most disease.

When we rely on patients to initiate contact with the healthcare system, access is a problem. So is stigma: if care is available, fear of a label motivates some patients to forego treatment. Even when providers see that mental illness contributes to a patient’s condition, it’s more easily ignored than a physical injury of similar magnitude, and cultural views of mental illness are part of this.

Although it’s ubiquitous to (and sometimes celebrated in) our culture, stress is a mental health topic. Like anything, stress can be constructive if we deal with it well or harmful if we cope with it poorly. It can provoke real physical symptoms in otherwise healthy people.

Chronic, unmanaged stress weakens our immune systems, which means some amount of disease can be prevented through its treatment. Stress can stimulate accumulation of bodyfat by keeping cortisol high, and interventions like mindfulness-based stress reduction can help to manage the stress hormone. We prescribe drugs for depression which change the way neurotransmitters behave in the brain, but exercise also can influence the way those chemicals act. If we’re seriously dedicated to helping people achieve better health, we shouldn’t treat meaningful lifestyle changes as something ancillary to other medical care.

It’s not always easy to discuss mental health topics or to find the right services for our patients, but it is something that we can improve without major change. Patients come in to our system and we treat problems which are sometimes secondary to those with which they need the most help, because that’s how healthcare is made to work right now. We operate as though we’re walled-off from one another, and when patients are in our shrinking areas of focus, we discuss only things we know how to help solve. The result is sometimes unclear ownership of a problem: a real barrier created by artificial divisions. It’s difficult enough to get these patients in contact with service at the right time, and we shouldn’t be making it more difficult to get to the right type of care.

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