As a part of my series about “The Future of Healthcare” I had the pleasure of interviewing Dr. Tim Ihrig who has spent his career caring for the most seriously ill people of all ages. He has sat as a board member for one of the larger healthcare systems in the U.S andis the Chief Medical Officer of Crossroads Hospice and Palliative Care and founder and Chief Executive Officer of Ihrig MD & Associates.
Thank you so much for joining us! Can you tell us a story about what brought you to this specific career path?
Harold. Harold was my very first patient. I’ve shared this story many times over the years.
It was my first day with the long, white-coat and I was the on-call resident at a Veterans Administration Hospital. Harold was in his late sixties and came to the emergency department with a primary complaint of headaches that had been getting worse and worse over the past month or so. A CT scan revealed that he had widely metastatic cancer — it had spread throughout his body including his brain, thus the headaches. The attending physician instructed me to share with Harold and his family the findings, prognosis and options for care. While we didn’t know the type of cancer, this was a moot point — people do not recover from such extensive disease.
As I was only a few hours into my career as a physician, I did the only thing I was absolutely sure of. I walked into Harold’s room, sat down, took his hand, took his wife’s hand and just breathed.
After a few moments he said, “It’s not good news is it, sonny?”
I said, “No.”
And so we talked and we listened and we shared. After a bit I asked what it was that brought meaning to Harold. I asked, “What is it that you hold sacred?”
He replied, “My family.” He had a wife and two teenage daughters.
I asked what he would like to do. He slapped me on the knee and said, “I’d like to go fishing.”
I said, “That, I know how to do.”He went fishing the next day. He died a week later.
Harold, and all the “Harolds” throughout my career, exemplify the tremendous opportunity we have to connect to a broader sense of the human condition beyond ourselves. The key and challenge is moving beyond the linear algorithmic model of healthcare where things are done to you because you have X, Y or Z. This approach does not parallel the algorithm of life — especially when it comes to the seriously ill. This linear algorithm is static, the seriously ill need a flexible, dynamic model — one which mimics the algorithm of life.
The key is to be accepting of the true algorithm of life — the variability of the day-to-daywithin the context of knowing exactly what is going to happen [death] regardless of ailment, intervention, etc. Even more important is to realize and accept that we can’t overcome this inevitability despite a fervent belief in the linear algorithm. The fact is, we can’t beat Mother Nature. Notwithstanding, I wholeheartedly support being aggressive, “fighting” and “never giving up.” But we first need to define exactly what we are “fighting for” and align clinical endeavors (aggressive or not) with the realities of the human physiologic trajectory and, as always, what is sacred to the individual.
Essentially, not just as a physician, but as a human being, Harold inspired me to strive to care for people based on what is sacred to them regardless of diagnosis or age. I have focused on doing things with and for people, rather than doing things to them. I have rejected the existing healthcare transactional relationship in favor of a translational relationship — one where the patient is the true center of care.
Can you share the most interesting story that happened to you since you began your career?
The most interesting, huh. That’s tough. I think of everyone I’ve had the honor of walking beside on their journey and each has been unique. Perhaps that is the most interesting story of all — what I have learned from the collective experience.
The most simple truths are the most powerful and transcendent. Leading with “care” and absolute honesty transcend medicine. They often transcend fear as well.
If pressed, one of the most delightful memories I have however is of a 105-year old woman who was brought to the hospital by her family — four generations of them! This was many years ago. She had shortness of breath, an irregular heart rhythmand swelling in her legs. She was dying. She was dying from being old, not because there was anything wrong with her or anything that could be fixed. Her heart — her whole body — was physiologically worn out. A cardiology colleague recommended a cardiac catheterization, possible pacemaker implantation and various pharmacologic interventions. The patient very politely said, “No, thank you. I’d like to go home.”
She was quite gregarious and flirtatious. Curious, I asked her what the most amazing thing she had witnessed over the past 105 years. She became very still. Very quiet. She took my hand. She looked far beyond me, far beyond the walls of the room. A gentle crease etching upward on her lips, reminding me of my young daughter shyly smiling, she recalled her parents reading newspaper articles to her as a little girl about Orville and Wilbur Wright.
My colleagues, unable to see the reality, the inevitability, the absolute certainty of life right in front of them, missed this opportunity to care, to engage, to lean, to love, to grow.
Can you tell us about your “Idea That Might Change The World”?
I have been asked, “Dr. Ihrig, what do you believe is wrong with healthcare?” My answer, simply, “It doesn’t care. The healthcare industry is so focused on finding the “cure” that it, more often than not, overlooks what can be done to “care.”
We need to put the “care” back in healthcare. We need to be willing to truly engage with our patients and make sure their treatment program is a shared decision and a shared journey between practitioner and patient. We need to hold ourselves, classmates, colleagues accountable for our actions, beliefs and behaviors. We need to be a catalyst of truth. We need to be a new voice in healthcare so patients can find their own. We need to care.
My “big idea” is to start a revolution of thought which brings forth a shift in our understanding of life and how we practice medicine. We must deconstruct the current model of healthcare as it unequivocally lacks the ability to care for the most ill, vulnerable and dying people on the planet. In addition, it jeopardizes not only the global economy, but, more importantly, our own humanity.
We need to go beyond historic ways of thinking to solve these problems as it is the genesis for them. Indeed, as a colleague once said, “The electric light was not invented through the improvement of candles.”
Through the creation of a cognitive framework predicated on an undeniable physiologic certainty — The Inflection Period — delivered through a True Palliative Care perspective, we can expand beyond the linear algorithm of current medical education and clinical practice and overcome that which jeopardizes our way of life.
Such a revolution is the answer. It provides the opportunity to change the paradigm of medical practice by acting as both the philosophy predicating the deconstruction of this inadequate healthcare model, as well as the architecture of a new system that meets current and future needs in a truly person-centric and economically viable model.
Be certain this is not simply healthcare reform. Rather, it is about reforming how we care.
If you will indulge me…
As a youngster, I was afraid of the “closet-monster.” That formidable creature of childhood imagination lurking in the dark back of the closet who, if not for a brave parent coming into the room and turning on the light, might have snuck out during the night to do dastardly things.
This closet-monster, or simply, fear of the unknown, is one of the greatest frailties of humans — of all ages. It paralyzes and encumbers us, prevents us from seeking out options for our lives and, ultimately, following our own life’s plan based on what is sacred to us.
Put another way, this fear really stems from our desire for certainty. Its actual genesis is the conflictual relationship between this desire for certainty and the inherent nature of life. What we fear is not the unknown, but rather ambiguity. Life is fundamentally ambiguous. The only absolute certainty is that it will end someday when we die. Ironically, wanting and trying to control the day-to-day experience of being alive is paradoxical to living life.
In the practice of medicine this absolute certainty is rarely acknowledged and even less so accepted. Medical professionals emphatically tout clinical paths while describing their outcomes as “unknown,” for fear of being perceived as “stealing hope” from a “patient who is not ready to hear the truth.” This excuses us from fulfilling our fiduciary responsibilities, and in truth, is a false manipulation of the clinical narrative. As such, medicine ends up doing things “to” people rather than “for” and “with” them.
Taking off our long, white coats, most physicians can readily admit that widely metastatic cancer, significant heart, kidney, liver (name your organ of choice) failure, and many other very serious illnesses, are terminal — they will lead to death. Many diseases are progressive, irreversible and fatal processes but are rarely spoken of in these terms as physicians aren’t trained to view them as such.
More interesting however, is outside of such serious disease process, the inevitability of life is hardly ever seen, even when it is staring us in the face.
So why is this? Why can’t we, the ones entrusted to care for you, see the truth of life? While the course and end-result of many diseases is known, why are we unable to see it? Or, if we do, why can’t we share this truth with our patients?
The answer is that medical education and the system of healthcare — and even society as a whole — fail to acknowledge this absolute truth. The clinical acumen required to recognize when someone, regardless of age, has come to the proverbial “turning of the corner” of life is very rare. Rarer is a vernacular that can be used to describe this period and discuss it with people or colleagues even if one were insightful enough to consider its existence and relevance. As such, we are trained, and we practice, in a realm absent of any real understanding, discussion or acknowledgement of the natural physiologic processes of life.
Furthermore, the healthcare system lacks care options outside of its linear algorithmic approach of doing things to people based on the recognition of the what is happening — disease and debility — rather than the why it is happening.
Where has this steadfast adherence to the linear approach led us? It has brought us to the fulcrum of the tipping point of humanity.
Healthcare as a linear algorithmic model acts without “True Informed Consent” — where we as providers share with patients the full and absolute truth about their diagnosis and prognosis. The more common approach is for providers to cower behind comfortable half-truths: “It is uncertain.” “No one really knows.” “Only God knows.” “We can always try a third-round of chemotherapy and renal replacement therapy.” The result is that patients are prescribed a litany of interventions which, to a great extent, have no value for them. As a practical matter, we can define value as increased quality of life or life expectancy. But doing things to people, particularly things that are not aligned with what an individual holds sacred, constitutes extremely wicked and cruel acts.
As a long-time, practicing palliative care physician, I can say without reservation that, for this seriously ill population, the “things” that are done to patients most often serve to decrease quality of life — they actually can cause harm. Great harm. And, at times, potentiate death. In addition, using “Unknown” as it relates to prognosis or disease course is beyond a fabrication. In fact, I would go so far as to say it is often an outright lie. As a physician, I know exactly what is going to happen. I know the general course of the disease and can be fairly certain of its duration.
This lack of transparency — lack of true informed consent — leads to a loss of freedom, often coupled with increased physical, emotional, intellectual and spiritual suffering, and even death. Such atrocities are perpetuated every day by healthcare systems to people all over the world. And while I don’t believe providers are intentionally maleficent, at what point do we hold them (and healthcare systems) accountable for intentionally following a model which continues to perpetuate the aforementioned?
While insidiously iatrogenic compared to the atrocities of the last century, I suggest it is no less significant with respect to interrupting a common fiber of humanity — the desire to write the chapters of our lives.
Jonathan Glover, in his book, Humanity: A Moral History of the 20th Century, examines the atrocities of the 20thcentury. He offers that humans inherently have moral resources — primarily the ability to feel sympathy and regard for others — which can prevent such egregious things from occurring again. I suggest these moral resources have been subjugated by the linear algorithm thinking.
We can no longer hide behind technological advances — interventions, pharmacy, or anything else — under the guise that “We are doing what is best for our patients.” Because all too often, we simply aren’t. How can we do what is best for our patients if we don’t even tell them the truth and then ask what it is they want?
I suggest a True Palliative philosophical foundation allows us to unlock these moral resources while caring for the most seriously ill. True Palliative Care can overcome the paralytic nature of the linear model and its perpetuation of an overwhelming sense of loss of control experienced by patients, caregivers and providers. “True informed consent” will then become the norm and we can deliver on what a patient’s goals of care are regardless of diagnosis. Only then will we cease committing such atrocities and actually begin to truly care — thus tipping ourselves toward a better humanity.
The key is to be accepting of the true algorithm of life — the variability of the day-to-daywithin the context of knowing exactly what is going to happen [death] regardless of ailment, intervention, etc. Even more important is to realize and accept that we can’t overcome this inevitability despite a fervent belief in the linear algorithm. The fact is, we can’t beat Mother Nature.
Notwithstanding, I wholeheartedly support being clinically aggressive, “fighting” and “never giving up.” But we first need to define exactly what we are “fighting for” and align clinical endeavors (aggressive or not) with the realities of the human physiologic trajectory and, as always, what is sacred to the individual.
In an effort to support embracing this algorithm, I suggest the Inflection Period. This is the heretofore referenced physiologic absolute when, for most humans, there is period in their health journey when their bodies begin to decline, and they lose the capacity to recover or restore.
The Inflection Periodis that time when our body transitions away from what we perceive as normal “health” and eventually ceases having any capacity to heal, recover, restore or respond positively to interventions. It is a physiologic rather than chronologic process. It varies in length per individual. It is not a “failure of the body” rather a natural process. It is the time which precedes death.
As a mental construct, the Inflection Periodprovides a framework for understanding the physiologic reason we die. It is an attempt to define the actual “why” we all die. Understanding the “why” allows us to create the language to talk about it, more readily recognize it, and expand the means of caring for people experiencing it beyond the linear algorithm of healthcare.
In fact, I believe theInflection Periodis the time when the focus of health care efforts by medical professionals should change to reflect its reality. But again, in contemporary medical practice, this does not happen. The system is designed to continue to provide “curable” strategies even when cure is not possible, and disease mitigating strategies carry more burden than benefit. Such clinical interventions act as harmful stressors that can dramatically accelerate a patient’s decline.
This over-utilization of resources and interventions that have little chance of achieving good outcomes increases the cost of care. More importantly, such “care” is often contrary to patients’ values and wishes had they known the absolute truth of their condition and can introduce preventable suffering and even death itself.
I urge us to seek new ways of thinking and practicing medicine which elevate what is possible in healthcare and beyond. Deepening our understanding of life, as opposed to fearing death or thinking of it as the ultimate clinical failure, we transcend medicine and come closer to what it means to be a true caregiver in the modern age.
How do you think this will change the world?
How can it not? Absolute truths have always, and will always, change the world for the better. They allow us to reflect on who we are as individuals, communities, societies, peoples. Understanding the inevitable provides an opportunity to focus changing S-C-A-R-E-D to S-A-C-R-E-D and living our lives rather than merely striving to be alive. And yes, we can’t forget to realize the economic realities of “caring” as opposed to “doing.”
Was there a “tipping point” that led you to this idea? Can you tell us that story?
There wasn’t one specific moment or “tipping point.” Rather, the Inflection Period is the culmination of a career trying to find a singularity as to why a True Palliative Care model is the only care model that potentiates increased quality and often length of life for those living the last chapters of their lives regardless of age and/or disease. What has happened over the past twelve months however, is a recognition of needing to explain the “why” we die. It is the proverbial Sir Issac Newton sitting under the apple tree and bringing forth the theory of gravity as to why the apple fell on his head.
What do you need to lead this idea to widespread adoption?
A national / global platform to engage all — public, policy makers, healthcare payers, systems, providers and educators. Opportunities that reach a broad audience — NPR’s Fresh Air, a special episode of Oprah, NYT op-ed, WSJ, The View, 60-minutes, The Colbert Report. I seek to share truths about what healthcare systems in the United States are grounded on (a fee-for-service business model), as well as how we as physicians are educated (both the good and the bad). I wish to share perspectives on why things are the way they are and what is being done to overcome inadequacies of care.
I will also share real-life stories of individuals with whom I have walked a portion of life’s journey. I hope to engage many and promote active questioning about the why, what, and how of healthcare for the most vulnerable and ill.
My hope and intent is to start a movement of thought and inspire others to understand and demand a better system of care for themselves and their loved ones. I urge you to reach out, correspond with me and engage so that the truth can become clear and we amass a larger voice to affect positive change for all.
What are your “5 Things I Wish Someone Told Me Before I Started” and why. (Please share a story or example for each.)
I have two main things I wish I knew:
1. What have you learned from those times when life was easy? Nothing! Walking the journey seeking reform and challenging norms and historical legacies has brought me to where I am today.
2. How misaligned the healthcare system is with respect to true patient centricity and how aberrantadvocating for true informed consent, doing things with and for patients — leading with “care” — and attempting to uphold our fiduciary responsibilities as physicians is to that system.
While this has been an overriding theme during my clinical tenure, too many examples to count, one experience particularly stands out. Early in my career, the Chief Medical Officer (CMO) of the healthcare system I worked in called me to his office. He began to share how frustrated and angry many of the oncologists were that I offered clinical opinions to cancer patients when they asked about their prognosis and disease states. Many of these individuals, like Harold, had incurable cancers that were going to kill them. A majority of these people had never been told this truth and were, literally and figuratively, dying while continuing to receive horrifically aggressive chemotherapeutic interventions at the insistence of their doctors.
When empowered with the truth, many sought more honest engagements with these doctors and questioned the efficacy of continuing such treatments if they weren’t going to make any positive difference in the quality or length of their lives.
The CMO told me that I was no longer allowed to converse with oncology patients, that all future Palliative Care consultations were to be fielded by a nurse who would only discuss what the oncologist allowed them to discuss.
Based on the future trends in your industry, if you had a million dollars, what would you invest in?
Against 3+ trillion dollars, one million isn’t that much! If, however, I was fortunate enough to have a million dollars, I would:
-seek to establish center for educating, outreach and support based the truths we are tiling about today.
-actively seek later investments that could influence economic alignment within the healthcare system to reflect these truths.
Which principles or philosophies have guided your life? Your career?
Lead with “care,” tell the truth absolutely and listen to my heart.
Can you share with our readers what you think are the most important “success habits” or “success mindsets”?
What don’t I know. What do I know. Is what I know the truth. Connecting to a broader sense of humanity beyond one’s self always sets one up for exponential, synergistic experiences.
Some very well known VCs read this column. If you had 60 seconds to make a pitch to a VC, what would you say?
I offer the same conversation I’ve had with many business groups. The fulcrum of economic sustainability for your business, and every business globally, over the next three decades is healthcare expenditure in the United States. With all due respect, this is regardless of whether or not one cares for that proverbial elder relative from whom they possibly inherited their business.
Why? The sickest, most vulnerable 5% of our population is responsible for nearly 50% of health care expenditures and the sickest, most vulnerable 15% of our population is responsible for upward of 85% of health care expenditures. Currently this equates to nearly 20% of the gross domestic product (GDP) of the United States or nearly 3 trillion dollars in 2017. Approximately 10,000 individuals per day reach the age of 65 and upwards of 14% of them can be classified as rising-risk, high-risk sick and vulnerable individuals falling into the aforementioned category.
Simply following the slope of the line of per capita expenditure vs attributable population, we stand to exceed 60% of the GDP for health care expenditures for only 15% of the population in a very short time. Remembering that a majority of that expenditure serves neither to prolong life or improve its quality. Not to mention, it doesn’t prolong the lifespan of the US workforce and there are billions of dollars lost due to caregiver burdens — lost work days, decreased productivity, etc.
If this comes to fruition, the conversation ceases to be about health care for the most vulnerable individuals. Health care and healthcare systems will no longer exist — nor will much of anything else with which we’re familiar today — including your business. And, as the United States is the largest economy in the world, presuming it maintains a prominent position in the global markets, such a change would have implications extending far beyond our free-market, capitalistic society. To be certain, this is not merely a medicine crisis. Nor is it specific to one side of the political aisle or another. It is our crisis — a human crisis.
Action and investment in change need to be taken today by all prominent business leaders to ensure the opportunity for their existence tomorrow.
How can our readers follow you on social media?
Thank you so much for joining us. This was very inspirational.
Thank you. I appreciate the opportunity of engaging and sharing.