Answering questions together

Last weekend I travelled to Washington DC to help create a new model for government-funded medical research. As a parent of a child with special needs who spends most of my time thinking about children with special needs, this 150-person patient summit was one of the most diverse groups of patient stakeholders I’d ever been part of. People representing arthritis, cancer, and kidney disease, people representing geriatric and pediatric issues, people whose medical issues came into their lives as a result of a tragic medical error or because of the body’s natural tendency to try new things.

We were invited there by an innovative organization, the Patient-Centered Outcomes Research Institute, or PCORI. Funded by the Affordable Care Act, PCORI aims to do research differently: to pair patients and researchers to answer questions that patients and families really care about. The idea of professionals doing work with patients instead of to or for them is reaching higher and higher levels of our nation’s health research priorities. In other words, this is a really big deal!

Even leveraging the collective lived experience of the attendees gathered by PCORI’s committed leadership, creating a research model that supports authentic partnership is going to be tough. Here are a few challenges I can see from my experience supporting patient-(and family)-professional partnerships on a number of levels and some ideas for addressing the challenges:

  • Challenge: Many professionals and patients don’t yet appreciate the innovation that patient-professional partnerships bring.

“We’re all patients,” is a common refrain from professionals when entering into collaboration with patients for the first time. That may be true, yet if that were enough, our health care system would have achieved a level of patient-centeredness that would render initiatives like PCORI unnecessary. Including people who are able work collaboratively while still retaining the unique vantage point of their own stakeholder group is critical to producing ideas innovative enough to handle the challenges our health care system is facing.

Suggestions: While PCORI’s current structure of supplying large grants (nearly $1m each) to a small number of projects has the opportunity to create some huge research results, funding many smaller projects in the form of micro-grants might do more to flood the field of research with thousands of opportunities to experience the “magic moments” of partnership innovation, encouraging real culture change.

  • Challenge: Throughout history, trying to insert a less powerful stakeholder group (patients) into the paradigm of the more powerful one (research) often results in paternalism and tokenism.

It takes a skilled, supported patient to not become acculturated to the professionals’ perspective when they’re sitting in their conference room or in their labs. Patients are often invited to partner and then sent signals that their ideas are unreasonable, off-topic or too aspirational—basically, that they “just don’t understand the reality of the situation,” or the professional’s own paradigm. Eventually, they become tokenized, or present so that the organization can claim credit for including consumers without actually changing.

Suggestions: PCORI must aggressively equalize the power dynamic from the outset. Make parity of participation (equal ratio of patients to all other stakeholders combined on a project) and compensation a requirement—including in their own leadership. Give higher scores to grant applications that offer patient-generated ideas and patient-driven projects. Teach the research community partnership skills. Putting patient groups in charge of awarding the funds would be a radical approach but could even out the power dynamic effectively.

  • Challenge: It’s easy to treat patient engagement as an ancillary function of whatever it is you’re trying to partner around.

When patients are invited into existing professional structures to partner, professionals often think that patients are the only ones who need to learn new things, that cultivating a healthy partnership is the job for a designated patient leader, or that partnering is a value deserving of resources only after the real work is done.

Suggestion: Instead of referring to “patient engagement,” frame the entire concept as “patient-professional partnership,” and make the partnering as important as other work. Accept that both sides will require training, new skills and new capacity to partner successfully. Select researchers and other stakeholders who demonstrate a commitment to partnership. Rather than assign a single person (usually a patient leader) to head up “patient engagement,” partner a patient and professional to model collaboration and manage this function. Similarly, partner patients and professionals as co-leaders throughout the organization to ensure that partnership stays central to the mission of the organization.

  • Challenge: Inadequate compensation creates circumstances in which only educated, engaged, connected patients are likely to participate.

Patients and caregivers are not often salaried employees. Participating in partnering often costs money: for childcare, additional nursing care for themselves or a family member or in lost income. When time is not valued through payment, only a lucky few have the means to participate. Also typical is that these patients’ contributions are devalued because the patients aren’t “regular people”—they’re too activated, navigate the system too well, or aren’t diverse enough.

Suggestion: PCORI can model transactions that will facilitate a more diverse participation by paying participants their time as well as expenses, and for participating in every role in their organization, including as grant reviewers and on their board and in leadership.

  • Challenge: The medical model paradigm favored by medical research, with its focus on body parts, diagnoses and disease labels, may be a source of conflict with patients.

Patients often take a radically more holistic perspective to medicine than researchers or even clinicians. Patients’ health care frame of reference is often a life course approach, a public health mindset and a medical home model blended into one, dismantling the silos of medicine, education, employment, transportation, housing, recreation and spirituality and blurring the lines between their own health and their families’ well-being.

Suggestion: Expand the scope of viable research questions to include non-diagnosis related questions, like identifying key activities of patient-professional partnership, the mechanisms of patient activation, care coordination, shared decision making, the impact of peer-to-peer (patient-to-patient and family-to-family) relationships, and the impact of social determinants on health. Fund projects agnostic to disease label to build a patient-centered research infrastructure: resources for patients on how to conduct research, access for patients on critical functions like an IRB and a venue for publishing, training on how to recruit their own researcher, and resources for all (not just PCORI) researchers on how to partner with patients.

PCORI leadership seems dedicated to doing this right. As a patient and family member, I recognize what a culture shift PCORI’s existence represents.

Do you have a research question that you’d like to submit to PCORI? Would you like to be a PCORI grant reviewer? Do you want to learn more about what PCORI does? Get involved and shape the future of medical research. Together we are better.

The Society for Participatory Medicine’s blog is also collecting  posts from other participants at last week’s event. Check them out.

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Durga Tool 7: Getting into the driver’s seat

Here’s another in my toolbox series of techniques that inspire me to live with joy, compassion and courage, as inspired by the Hindu goddess Durga  – my nominee for patron saint of special needs parents. 

In my 10 years as a parent of a child with significant medical and developmental challenges, I had significant “a-ha” change in my level of consciousness just a couple of years ago. So significant that it almost deserves a personal equivalent to the B.C. and A.D. of our Western calendar. That’s how big a deal it feels, even now.

Before this shift, I was naïve, in denial and passive. After this shift, I was empowered and engaged. It was as if after years of being a passenger in my son’s care, when doctors, early intervention professionals and teachers had been driving, I decided to take the wheel.

So what happened? Health care workers would say that I got activated. Educational experts would say I got engaged. Family leaders might say I became an advocate.

I would say that I finally understood that when it came to my son’s life, the buck stopped with me. I understood that no matter how respectful or knowledgeable the experts were, they couldn’t connect all the dots of my son’s needs. They didn’t have the knowledge or resources to. To ask them to was unrealistic and even unfair. And the healthcare and education systems that I assumed were always looking out for the best for us…well, if feels almost foolish now to say that I did think things worked that way.

Suddenly, I got it. And that realization pushed me to gain so many new skills, so much knowledge and confidence. Some might call it grace. It sure feels like it.

I don’t have any answers as to why I was lucky enough to want to get behind the wheel. I do have a lot of empathy for those who don’t. It probably depends on many things—in my own case, my own personal and cultural views on both authority and expertise, a lack of access to a peer who had been through it before, challenges coping with fear and anxiety, anger at feeling that life had dealt me a bad hand, but to name a few. Mostly, I think, it was a bone-deep sense of overwhelm, a false assumption that there were too many questions, too few answers, too much bad news and not enough me to go around.

Since then, I’ve become passionate and curious about what makes one person “wake up” to the idea that they are in the driver’s seat of their own and their child’s well-being, and another person assume that the professionals caring for them can know what they need better than they know themselves. If I could wish for one single miraculous insight for others, it would probably be this acceptance of the absolute need for personal responsibility. Without this, nothing else will get done.

In the health care world, professionals talk about family or patient “readiness,” or our openness and ability to make a change.  Before we “wake up” or become what they call an activated, engaged patient, we must spend time getting ready for that change. Maybe it’s not a switch that gets flipped, but a series of awakenings, of small changes that slowly builds our confidence in our own ability to lead.

Yesterday I got the chance to observe an intervention at a waiting room in a health clinic designed by an organization called the Right Question Institute. A medical student, armed with a simple pamphlet and a friendly way about her, approached patients waiting to see their doctors and coached them through a brief activity that helped them prepare three well worded questions for their doctor.

Is this the grace I have been wishing for others? Perhaps so. After so many years of trying to support others to get in the driver’s seat by enthusiastically telling them they could do it, I watched a few folks learn how.

When did you figure out that you needed to be in the driver’s seat? Did you always know? How to you encourage others to take charge?

See you out there on the highway…zoom zoom!