The Short White Coat: Transforming Care and the Patient Experience

Valmeek Vick Kudesia, M.D. VP of Clinical Informatics and System Design, Commonwealth Care AllianceTraditionally, the length of a doctor’s white coat is a reflection of his or her experience and seniority. Medical students start with a short white coat, like a white blazer, and senior doctors wear a knee-length white coat. During my internal medicine residency program at a large safety-net hospital, one of the senior medicine professors chose to wear a short white coat instead of the ‘traditional’ full length garment. When asked about his style choice, he would explain that, as every patient is different and he is constantly learning, he saw himself as an eternal student, in service to his current patient. He would tell us, “Learn from the routine. Learn something every time you care for a person. If you do that, you can’t help but be better the next time.”

If we take a step back, caregivers only have two fundamental purposes (either solo or as a team). The first is to relieve suffering and the second is to extend life. The transactions that envelop care providers, the person receiving care, and his or her family are all “overhead” or “friction” to those fundamental purposes. Our actions as caregivers are most effective when we take a holistic sense of a person’s health with all of his or her well-being, ills, happiness and suffering. In reality, it is ultimately the patient who will dictate their healthcare, not a 15 minute clinic visit or a hospital stay. The best system to care for health (vs. healthcare system) would bring caregivers, their actions and their attention to the person’s life as a whole, and not artificially boxed into a specific time and location, i.e. care on the person’s terms not the system’s terms.

The best system would also propel rapid learning – like the Institute of Medicine’s rLHS model – of the most important interventions for an individual person across medical, behavioral and social domains. That is to say, “we” (care givers, the system) would wear the short white coat, rapidly learn what mattered most relative to the patient in a holistic sense, and perform the best tailored interventions for that person. Drawing from my safety-net roots, often we, as medical professionals, have the most to learn about vulnerable and underserved individuals, often including the dual eligible Medicare/ Medicaid population.

When working to build the most effective patient-centric care plans, technology is becoming more prominent in the overall process

For example, medically speaking the best way to control a patient’s high blood pressure would be with medicine or a special diet. However, for a particular patient, the most effective treatment might be to connect that person with local community supports so the individual gains a sense of agency over his or her own health. Once the patient has effectively engaged in their own care, they would understand the need for a medication regimen with BP telemonitoring. For another person, the most effective method for treatment for the same health concern may be a simple text message medication reminder specifically timed every morning when the person is in transit on the bus to work, followed by a text message to a family member, loved one or caregiver, who then reinforces the importance of medication adherence. For some individuals wrestling with behavioral health needs and substance abuse, an on demand “ride-share”-like service to return to clinic is essential to defend against specific situations that increase risk of relapse or the day-to-day struggle with addiction.

When working to build the most effective patient-centric care plans, technology is becoming more prominent in the overall process. The broad application of healthcare technology has been mostly system-centric and focused on transactions or processes of our healthcare system e.g. order, approve/deny, bill, track services, schedule or document specific data. However, the maturing of “care outside a clinic” solutions – including tele-presence, telemedicine and telemonitoring, clinical predictive and prescriptive analytics, and information integration (in a single health record) provides an opportunity to bring the best care to patients, on their own terms. With these advancing technologies, risk-bearing entities that combine managed services and direct care will see major changes and flexibility to their business and care models, as they expand their view of an individual’s needs across the medical, behavioral and social dimensions.

The combination of technologies will amplify the scope of the “ambulatory ICU model,” for the individuals with the most complex medical, behavioral, or social care needs, and will make elements of the ambulatory ICU model available on demand for individuals with less-complex needs. For example, home glucometer measurements from a patient can be integrated into a single health record and trigger remote or face-to-face care and coordination between a community health worker, the patient’ personal care attendant, the organization’s pharmacy service, and the patient’s behavioral health specialist.

The potential for such rapid coordination widens the portfolio of interventions, i.e. the best action might be transport and different home health services vs. a new medication regimen, allows for therapeutic intervention earlier in the timeline of acute issues, and targets re-engagement of patient or social supports. Keeping the short white coat philosophy in mind, we as care providers and medical professionals within the healthcare system we inhabit, can learn from all patient experiences to continually contribute to our own understanding of what is best for those we care for. For the benefit of the all future patients, we are always looking for new, innovative ways to transform and enhance their experience.