What makes us get sick? Look upstream | Rishi Manchanda

A Different Approach to Healthcare

In this section, the speaker discusses the need for a fundamentally different approach to healthcare that focuses on improving health where it begins, rather than just treating symptoms in clinics.

The Need for a Different Approach

• The speaker has cared for various individuals, including homeless veterans and working-class families, which has led them to believe that a different way of looking at healthcare is necessary.

• Healthcare should move beyond just treating symptoms and instead focus on improving health where it begins - in our daily lives.

Veronica's Story: A Different Approach in Action

This section highlights Veronica's case as an example of how a different approach to healthcare can lead to better outcomes.

Veronica's Chronic Headache

• Veronica came to the clinic with a chronic headache that had been ongoing for years. She had previously visited emergency rooms multiple times but did not find relief.

• The speaker emphasizes the importance of taking a different approach when treating patients like Veronica.

Addressing Housing Conditions

• The medical assistant asked routine questions about Veronica's chief complaint and vital signs but also inquired about her housing conditions. It was discovered that she had roaches, water leaks, and mold in her home.

• This information helped the speaker understand that Veronica's symptoms were related to her living conditions.

A New Diagnosis and Treatment Plan

• After examining Veronica and asking further questions, the speaker diagnosed her with chronic allergies, migraine headaches, and sinus congestion related to her living environment.

• Along with prescribing medications for symptom relief, the speaker referred Veronica to a community health worker who could address her housing issues and potentially involve a public interest lawyer if necessary.

Positive Outcomes

• Veronica returned to the clinic a few months later and reported significant improvement in her symptoms. Her overall health had improved, and she spent less time seeking emergency care.

• Additionally, her sons' health, particularly one with asthma, also improved. The positive changes in Veronica's health were attributed to both the treatment plan and the improvements made in her home environment.

[t=0:00:13] A Different Approach to Healthcare

In this section, the speaker discusses the need for a fundamentally different approach to healthcare that focuses on improving health where it begins, rather than just treating symptoms in clinics.

The Need for a Different Approach

• The speaker has cared for various individuals, including homeless veterans and working-class families, which has led them to believe that a different way of looking at healthcare is necessary.

• Healthcare should move beyond just treating symptoms and instead focus on improving health where it begins - in our daily lives.

[t=0:00:33] Veronica's Story: A Different Approach in Action

This section highlights Veronica's case as an example of how a different approach to healthcare can lead to better outcomes.

Veronica's Chronic Headache

• Veronica came to the clinic with a chronic headache that had been ongoing for years. She had previously visited emergency rooms multiple times but did not find relief.

• The speaker emphasizes the importance of taking a different approach when treating patients like Veronica.

Addressing Housing Conditions

• The medical assistant asked routine questions about Veronica's chief complaint and vital signs but also inquired about her housing conditions. It was discovered that she had roaches, water leaks, and mold in her home.

• This information helped the speaker understand that Veronica's symptoms were related to her living conditions.

A New Diagnosis and Treatment Plan

• After examining Veronica and asking further questions, the speaker diagnosed her with chronic allergies, migraine headaches, and sinus congestion related to her living environment.

• Along with prescribing medications for symptom relief, the speaker referred Veronica to a community health worker who could address her housing issues and potentially involve a public interest lawyer if necessary.

Positive Outcomes

• Veronica returned to the clinic a few months later and reported significant improvement in her symptoms. Her overall health had improved, and she spent less time seeking emergency care.

• Additionally, her sons' health, particularly one with asthma, also improved. The positive changes in Veronica's health were attributed to both the treatment plan and the improvements made in her home environment.

The Importance of an Upstream Approach to Health

In this section, the speaker discusses the importance of taking an upstream approach to health and addresses various factors that impact community health.

Understanding Community Health Factors

• Substandard housing and food insecurity are major concerns in communities like South L.A.

• Other communities may face different challenges such as transportation barriers, obesity, access to parks, or gun violence.

The Three Friends Parable

• The speaker introduces the concept of an upstream approach using a parable of three friends encountering children in need of rescue in a river.

• The first friend focuses on rescuing those at immediate risk.

• The second friend builds a raft to prevent people from reaching the dangerous waterfall.

• The third friend swims upstream to find out why children are being thrown into the water.

Healthcare Professionals' Roles

• Healthcare professionals can be categorized into three roles: rescuers (specialists), raft-builders (primary care clinicians), and upstreamists (those who address root causes).

• Rescuers provide critical care during emergencies.

• Raft-builders manage chronic conditions and provide preventive care.

• Upstreamists focus on addressing social determinants of health and creating systems that connect people with necessary resources outside clinical settings.

Impact of Living and Working Conditions

• Living and working conditions have more than twice the impact on our health compared to our genetic code.

• These conditions include environmental factors, social fabric, and behaviors.

• Pills and procedures administered by doctors have less impact on overall health compared to living conditions.

Examples Highlighting the Influence of Social Factors

• Proximity to green spaces like parks has been found to lower the risk of heart disease, regardless of socioeconomic status.

• Living and working conditions can shape our genetic code through epigenetic mechanisms.

• Zip code is often a more significant factor in determining health outcomes than genetic code.

The Need for Healthcare Professionals to Address Upstream Issues

• Healthcare professionals should recognize the importance of addressing upstream issues for better health outcomes.

• The speaker emphasizes the need to go beyond traditional medical interventions and consider social determinants of health.

[t=0:09:59] Conclusion

In this section, the speaker concludes by highlighting the significance of addressing upstream factors in healthcare.

• Veronica's question about why her doctors did not address these issues prompts reflection on the role of healthcare professionals in addressing social determinants of health.

• The speaker encourages healthcare professionals to take an active role in understanding and addressing upstream factors that impact community health.

The Challenges in Addressing Healthcare Issues

In this section, the speaker discusses the challenges in addressing healthcare issues and the reasons behind them.

Paying for Volume, Not Value

• Healthcare often focuses on treating symptoms rather than addressing underlying conditions.

• The current payment system incentivizes volume of services provided rather than value or health outcomes.

• Doctors and hospitals are paid based on the number of services they provide, not necessarily on how healthy they make patients.

"Don't Ask, Don't Tell" Approach

• There is a lack of emphasis on addressing upstream issues in healthcare.

• Upstream issues refer to factors such as living and working conditions that contribute to health problems.

• Despite awareness among physicians about the importance of upstream issues, there is a lack of confidence in addressing them effectively.

Gap Between Awareness and Action

• While physicians recognize the significance of upstream problems, only one in five doctors feel confident enough to address these issues.

• There is a gap between understanding that patients' context matters and having the ability to take action within existing healthcare systems.

The Role of Upstreamists in Healthcare

This section explores the concept of upstreamists and their role in transforming healthcare by focusing on root causes and mobilizing resources.

Defining Upstreamists

• Upstreamists are individuals who identify and address root causes of health problems.

• They can be doctors, nurses, care managers, social workers, or other clinicians.

• What matters most is their ability to implement a process that transforms healthcare delivery.

The Process of an Upstreamist

1. Identify Clinical Problem: Upstreamists start by identifying specific clinical problems among certain patient groups (e.g., children with asthma).

2. Identify Root Cause: Instead of solely looking at genes or behavior, upstreamists analyze living and working conditions that contribute to the problem (e.g., air pollution near a patient's home).

3. Mobilize Resources: Upstreamists bring together resources from various sectors, including public health and legal professionals, to create solutions that address the root causes.

The Need for More Upstreamists

• There is a shortage of upstreamists in the healthcare system.

• Estimates suggest that there should be one upstreamist for every 20 to 30 clinicians.

• Initiatives like Health Begins aim to train and increase the number of upstreamists in order to address this gap.

Transforming Healthcare through Upstreamism

This section highlights the impact of upstreamism on healthcare systems and shares stories of individuals benefiting from this approach.

Changing Clinicians' Confidence

• Training upstreamists helps change the "don't ask, don't tell" mindset among clinicians.

• The goal is to empower clinicians and their systems with confidence in addressing living and working conditions as part of healthcare delivery.

• There has been a significant increase in confidence among clinicians who have undergone upstreamist training.

Stories of Transformation

• Upstreamism has led to remarkable changes in healthcare outcomes.

• Individuals like Veronica have experienced firsthand how addressing root causes can improve their overall well-being within the healthcare system.

• However, there is still a need for more upstreamists to meet the demand for comprehensive care.

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New Section

In this section, the speaker emphasizes the importance of considering the context of patients' lives in healthcare. They discuss how doctors and nurses can improve patient care by asking about patients' lives, and how healthcare systems can collaborate with public health agencies to identify patterns and address upstream causes.

Focusing on Patients' Lives

• Doctors and nurses should ask about the context of patients' lives to provide better care.

• This approach is not just for better bedside manner but also for a higher standard of care.

Collaboration with Public Health Agencies

• Healthcare systems and payers should work with public health agencies to analyze data together.

• The goal is to identify patterns in patients' lives and determine upstream causes.

• Resources should be aligned to address these identified issues.

Training the Next Generation

• Medical schools, nursing schools, and other health professional education programs can train future healthcare professionals in an upstream approach.

• Certification of community health workers as a backbone of the upstream approach is essential.

• More community health workers are needed for an effective healthcare system transformation.

New Section

In this section, the speaker highlights the role of patients in improving their own health. They encourage patients to engage with their doctors, clinics, and nurses by asking about potential barriers to health in their living and working environments. The importance of doctors listening to patients' concerns is emphasized.

Empowering Patients

• Patients should proactively inquire about potential barriers to their health in their living and working environments.

• Awareness of these barriers is crucial for addressing them effectively.

Doctor-Patient Collaboration

• If patients raise concerns about problems such as housing or transportation, doctors need to listen and work together with patients to improve their health.

• The focus should be on addressing the root causes of health issues.

New Section

In this section, the speaker emphasizes that health is not solely an individual responsibility but a common good. They highlight the importance of recognizing the impact of living and working conditions on health outcomes and advocate for collective efforts to improve overall well-being.

Health as a Common Good

• Health is not just a personal responsibility or phenomenon; it is a common good.

• Understanding the context of where people live, work, eat, and sleep is essential for promoting better health outcomes.

• Actions taken for self-improvement should also extend to improving conditions for others facing challenging circumstances.