Reviving the Doctor-Patient Relationship
Dr. Vikas Saini, MD is the president of the Lown Institute, which aims to change the healthcare system to improve patient care and address health care disparities. After studying philosophy at Princeton and medicine at Dalhousie University, Dr. Saini completed his residency at Baltimore City Hospitals/Johns Hopkins Bayview and completed his fellowship under Nobel Peace Prize awardee Dr. Bernard Lown at Brigham and Women’s Hospital. He then co-founded the medical device company Aspect Medical Systems, helping to initiate development of the BIS Monitor, a device used to monitor anesthesia. Dr. Saini returned to the Lown Institute in 2007, and as president has pioneered efforts like the Avoiding Avoidable Care Conference and the RightCare Alliance.
Earlier in the fall, I read a piece in the Boston Globe describing how Dr. Saini and colleague Dr. Aaron Stupple, both donning white coats, were stopping pedestrians in Boston Common to ask them about their experiences with the healthcare system. I sat down to talk with Dr. Saini about what he learned from these “Listening Booths” and what he thinks young physicians can do to improve patient-centered care.
R: Tell me about your path to medicine.
Dr. Saini: My path to medicine was more humanistic, because the technical side of medicine never appealed to me. In fact, I remember as a rebellious teenager telling my Dad there was no way I was going into medicine and becoming another technocrat. But I took a year off as an undergraduate and travelled across Europe and to India by land. It was in the course of that year that I realized that being a doctor would be something that would speak to me in a different way. I saw the fact that there was a reliable one-on-one connection as a doctor with a patient. The value of that connection made everything else more significant. The fact that you could help someone one-on-one was a refuge from all the ways in which you might think you are doing things to help that might not work—you could do research and it comes up dry, you could do policy and it comes up with unintended consequences. It seemed like there was something irreducibly good about that connection, and that’s what led me to apply.
R: What did Dr. Bernard Lown teach you about the art of healing?
Dr. Saini: The most important thing he modeled was that everything was on the table. You could ask about symptoms, of course. You could get a history, of course. But, really, more than anyone else I’ve ever known, he emphasized that you couldn’t understand what the right path would be, what the right treatment would be if you didn’t really understand the patient as a whole human being in a social context, with family dynamics, with all the things that go into making someone who they are. And it wasn’t that he preached this, he showed you. He would know the dynamic with the spouse, the dynamic with the children, [and] he would invoke it when he was talking.
He also taught that it is all important, all sorts of non-verbal stuff—how you position yourself, taking time, touching people, sitting down and not standing at the head of the bed. On rounds, it was a delight. It was the first time you could discuss Tolstoy, German philosophy…it was a blast. All of that made me realize that there were whole parts of me that I thought were just private and weren’t part of medicine. He showed me that they’re very much who I am and you could only be a good doctor if you were yourself. You have to have all of yourself available.
R: How do you think recent trends in healthcare have affected doctors’ ability to practice the values Dr. Lown taught?
Dr. Saini: It’s awful. It’s awful because everyone is trapped in the logic of the marketplace. And we have created a fetish over the last thirty years of what the market can do. There are some market elements that can help, and some of them can be disruptive and important. But at the end of the day, the reason the core dysfunctions of the system have become increasingly problematic for all of us—doctors, nurses, patients—has to do with the fact that this is a public good and that the way you’re going to solve some of the problems and realize the change in the system actually requires public input. It requires intentional public debate, discussions, and democratic input. It requires a range of things that market mechanisms aren’t going to do.
For example, doctors do not have the kind of time they need with patients. They don’t have it because they’re on the treadmill, pushed by productivity, because much of what we measure is tied to productivity. The perverse incentives really aggravate the situation. They are told the value is coming, but they have to make ends meet now.
R: What is the RightCare Alliance doing to address that?
Dr. Saini: Our goal is to grow a network of clinicians large enough that in any given community we can begin to engage directly with our peers and with our patients and communities to talk about fundamental things. For example, it is clear to us that primary care as we currently have it is not the primary care that we need to have in a high-performing system. If we could have the primary care we need, it should be the bedrock of any high-performing system. That means the primary care community has to change. And that means the rest of the healthcare system has to change.
The other issue is that too many things are in the hospital and can be moved. There are many disparities in access. For these communities, access doesn’t necessarily mean another MRI machine, but rather home-based or walkable community-based primary care. Those are things we think we should talk about. Because if we can focus on values, then what to do will flow from that. If we keep getting hung up on specifics on what to do too early and forget the core values that drive them, we will leave people behind.
R: What did you learn from the Listening Booths?
Dr. Saini: I learned a few things:
One: A lot of people who are healthy feel that healthcare is about having insurance. They have never interacted with the system, they don’t have any worries, they make sure they have insurance because they know that is important and then they believe they’re in good shape. And it’s only when you get sick and deal with the dysfunctional system that they actually begin to see what it actually feels like.
Two: There is a lot of fragmentation in the system and people are suffering from it.
Three: Rich or poor, black or white, a core definition of good care is precisely what we started this conversation with—everybody wants a relationship of caring and trust. That really matters to people. This is not a slogan.
R: How have you been able to maintain your interest in the humanities?
Dr. Saini: It’s a struggle. It’s really hard in the clinical years—I think that we should be giving our trainees space for that. People take time to get another year of credentials. People take time to learn another technique. All of which is going to enhance and burnish your career or earning potential. People do that as an investment. I think that if you plan to be a really good doctor, you have to consider reading literature, reading poetry, staying in touch with your own inner humanity as an investment in being a good doctor. You have to consider it that way and give it that respect and then carve out the time. You can’t do that continuously. There are times when you have to set it aside when you’re just too busy.
R: What is your advice to budding clinicians or medical students?
Dr. Saini: Join the Right Care Alliance! When you’re starting out, uncertainty is really hard to manage. You want to just know “the truth.” It’s scary, there’s so much that could go wrong. It’s really hard for us to be comfortable with uncertainty. Understand the basics of studies, of statistics, and of how statistics can be spun. I think there’s a growing movement across the board to recognize that the way in which we take knowledge and translate it into practice has been very inadequate. And that if we’re going to make it adequate, all of us need to really understand what we truly know and what we don’t. You’re not always going to know everything, but it’s an attitude—that when you examine something, you have to look at it with a very skeptical and critical eye.