The Heroism of Incremental Care

Relationships matter. The important relationships in our lives influence our thoughts and our behaviors. Relationships are the way we learn to trust. I was reminded of this essential truth while reading an impressive article in this month’s The New Yorker magazine by Dr. Atul Gawande titled “The Heroism of Incremental Care.”

Dr. Gawande, a surgeon and author of several best-selling books on medicine, makes a compelling case for the importance of the relationship between patients and their primary care doctor as the key to reduction in the cost of healthcare for our government and for all Americans.

Incrementalism in healthcare, according to Gawande, is the focus on an individual’s health over time based on the doctor’s knowledge of not only the patient’s health history but also the patient’s personality, attitudes, fears and concerns.

Incremental care is also a process of building a relationship over time between the patient and his or her primary doctor based on trust that the doctor really knows me and has my best interests in mind.

We are far more likely to follow the recommendations of a friend or loved one who really knows us and truly cares about what’s best for us. If a patient believes that their doctor really knows them and really cares about what is best for them, they are also far more likely to follow the doctor’s advice.

This is in contract to the episodic care based on treating health problems rather than preventing health problems that is the basis of our current healthcare system today. Currently, not only specialists but also most primary care doctors engage in episodic care with patients based on the patient’s chief complaint or diagnosed condition.

Most primary care physicians don’t have time to build trust relationships with patients because the encounter is too brief. Where there is no trust relationship, patient compliance and adherence is much less likely.

With the rapid increase in the number of U.S. citizens with high-deductible health plans, people are more inclined to defer care because the cost burden is 100% on the patient’s pocketbook. This, in turn, leads to more serious, untreated health conditions that could have been avoided or at least mitigated if the patient prioritizes health over cost.

If patients do not have a trust relationship with their doctor who they believe really cares about them, they will always prioritize cost over health.

The direct primary care movement (DPC), where the patient pays a relatively modest monthly fee to their doctor for all primary care services, including preventive care – bypassing the health insurance intermediary – has been slow to develop.

DPC more recently appears to be gaining traction as more Americans are forced into high-deductible plans that make them feel like they don’t even really have insurance benefits because they have to pay cash for medical care for a longer period each year plus a monthly premium and they simply can’t afford to see a doctor – so they don’t.