Winter 2014

Our Ailing Patient

U.S. medicine is not delivering the value it should, says Rishi Manchanda, who offers a prescription for the future

By Bruce Morgan

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“We have lopsided spending in our country, where we spend more heavily on health services than we do on social services,” Manchanda told his audience. Photo: Kelvin Ma

The quality of American health care is not so good: We die sooner and are in poorer health than people living in Canada or France. We also pay a great deal more for medical care than those in other industrialized nations and get less, Rishi Manchanda, A97, M.D./M.P.H., ’03, told a Tufts audience recently.

That dire diagnosis was confirmed by the 2013 Institute of Medicine report, U.S. in International Context: Shorter Lives, Poorer Health, he said. The report was shocking in its conclusions. “We uncovered a strikingly consistent and pervasive pattern of higher mortality and inferior health in the United States, beginning at birth,” it read. It is possible to remake American medicine, Manchanda said, by looking beyond the walls of the doctor’s office or clinic. 

Manchanda is a visionary young physician who heads HealthBegins, an initiative to improve the health of vulnerable populations in Los Angeles. He is also the author of The Upstream Doctors: Medical Innovators Track Sickness to Its Source (TED Books, 2013). He returned to Tufts in October as part of the Common Reading Book Program, co-sponsored by the medical school and the Jonathan M. Tisch College of Citizenship and Public Service at Tufts. The digital book was provided to all members of this year’s entering medical class in an effort to spark discussion about timely and provocative issues affecting medicine.

A central part of the problem with health care in America has to do with how the system is organized, Manchanda said, citing its short-term focus on patient symptoms and its fee-for-service structure that encourages recurrent testing without necessarily getting to the root of a particular problem. 

Manchanda cited the case of Veronica, who came into his clinic in South Los Angeles a few years ago complaining of constant headaches. She already had seen a number of doctors, but none of them seemed able to resolve her complaint, and now she was struggling with big bills for the treatment she had incurred along the way. “Veronica was not only still sick, but she was actually worse off,” Manchanda noted. “Now she owes money, and she’s missed time from work, and she’s missed time with her family.” 

It was only when Manchanda took time to notice on a supplemental form that her apartment contained mold, water leaks and roaches that something clicked. He realized that because of her subpar living conditions, she was likely suffering from migraines related to chronic allergies and sinus congestion. After he conferred with a local housing organization, which intervened to improve the conditions in Veronica’s apartment, her health began to improve. 

How common is a story like this? All too common, Manchanda said, because of the fragmented way that American medicine is set up. Veronica had been bounced from doctor to doctor, test to test, over many months. “I went looking for a villain in this case,” Manchanda said, “but I couldn’t find one. What I found is that people in the system had done fine—everyone was swimming in the lanes. But collectively we were coming up short.” 

Manchanda believes that doctors need to pay more attention to the social determinants of health as part of routine care. Those with a wider perspective on health than what a brief office visit might suggest he calls “upstreamists.” These are doctors who examine the patient’s entire environment—where they live, where they work, the quality of the air they breathe—in their diagnostic scope. As one example of the wisdom of this approach, he cited a recent British survey of some 40 million patients that found that people who live close to public green spaces are less likely to die from circulatory disease than those who do not. 

Upstreamists are doctors who examine the patient’s entire environment—where they live, where they work, the quality of the air they breathe—in their diagnostic scope.

The narrow focus of medical care prevalent in the U.S. makes neither medical nor social nor economic sense, Manchanda maintained. “The system we’re in right now is this perverse situation,” he said. “We have lopsided spending in our country, where we spend more heavily on health services than we do on social services.” Veronica’s moldy apartment was one consequence of the tilt.

Manchanda’s message may sound revolutionary, and in many ways it is, but he expressed his vision diplomatically, saying the health-care system requires a better “alignment” of existing resources. If American medicine had 25,000 “upstreamists” plugged into the system and exerting their influence, he believes we’d all be better off when we go to see the doctor. 

The time may be right in our national conversation for the common-sense perspective of doctors who take a wider view for any diagnosis they make, said Manchanda, who has been meeting and conferring with fellow “upstream” enthusiasts to see what they can come up with to improve American medicine. “Part of the zeitgeist right now has to do with finding value,” he observed. Bruce Morgan 

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