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TEDSalon NY2014

Rishi Manchanda: What makes us get sick? Look upstream.

August 7, 2014

Rishi Manchanda has worked as a doctor in South Central Los Angeles for a decade, where he’s come to realize: His job isn’t just about treating a patient’s symptoms, but about getting to the root cause of what is making them ill—the “upstream" factors like a poor diet, a stressful job, a lack of fresh air. It’s a powerful call for doctors to pay attention to a patient's life outside the exam room.

Rishi Manchanda - Physician
Rishi Manchanda is an "upstreamist." A physician and public health innovator, he aims to reinvigorate primary care by teaching doctors to think about—and treat—the social and environmental conditions that often underly sickness. Full bio

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Double-click the English subtitles below to play the video.
For over a decade as a doctor,
00:12
I've cared for homeless veterans,
00:14
for working-class families.
00:17
I've cared for people who
live and work in conditions
00:19
that can be hard, if not harsh,
00:23
and that work has led me to believe
00:25
that we need a fundamentally different way
00:27
of looking at healthcare.
00:29
We simply need a healthcare system
00:31
that moves beyond just looking at the symptoms
00:33
that bring people into clinics,
00:35
but instead actually is able to look
00:36
and improve health where it begins.
00:39
And where health begins
00:42
is not in the four walls of a doctor's office,
00:43
but where we live
00:46
and where we work,
00:48
where we eat, sleep, learn and play,
00:50
where we spend the majority of our lives.
00:53
So what does this different
approach to healthcare look like,
00:56
an approach that can improve health where it begins?
00:59
To illustrate this, I'll tell you about Veronica.
01:02
Veronica was the 17th patient
01:06
out of my 26-patient day
01:08
at that clinic in South Central Los Angeles.
01:10
She came into our clinic with a chronic headache.
01:13
This headache had been going on
01:15
for a number of years, and this particular episode
01:16
was very, very troubling.
01:18
In fact, three weeks before she came to visit us
01:21
for the first time, she went to an
emergency room in Los Angeles.
01:23
The emergency room doctors said,
01:27
"We've run some tests, Veronica.
01:29
The results are normal, so
here's some pain medication,
01:31
and follow up with a primary care doctor,
01:34
but if the pain persists or if it worsens,
01:36
then come on back."
01:38
Veronica followed those standard instructions
01:40
and she went back.
01:43
She went back not just once, but twice more.
01:45
In the three weeks before Veronica met us,
01:48
she went to the emergency room three times.
01:50
She went back and forth,
01:52
in and out of hospitals and clinics,
01:54
just like she had done in years past,
01:56
trying to seek relief but still coming up short.
01:58
Veronica came to our clinic,
02:01
and despite all these encounters
with healthcare professionals,
02:03
Veronica was still sick.
02:06
When she came to our clinic, though,
we tried a different approach.
02:09
Our approach started with our medical assistant,
02:12
someone who had a GED-level training
02:15
but knew the community.
02:17
Our medical assistant asked some routine questions.
02:18
She asked, "What's your chief complaint?"
02:21
"Headache."
02:23
"Let's get your vital signs" —
02:25
measure your blood pressure and your heart rate,
02:27
but let's also ask something equally as vital
02:29
to Veronica and a lot of patients like her
02:31
in South Los Angeles.
02:33
"Veronica, can you tell me about where you live?
02:35
Specifically, about your housing conditions?
02:38
Do you have mold? Do you have water leaks?
02:39
Do you have roaches in your home?"
02:42
Turns out, Veronica said yes
to three of those things:
02:44
roaches, water leaks, mold.
02:46
I received that chart in hand, reviewed it,
02:49
and I turned the handle on the door
02:52
and I entered the room.
02:53
You should understand that Veronica,
02:55
like a lot of patients that I have
the privilege of caring for,
02:57
is a dignified person, a formidable presence,
02:59
a personality that's larger than life,
03:02
but here she was
03:04
doubled over in pain sitting on my exam table.
03:05
Her head, clearly throbbing, was resting in her hands.
03:08
She lifted her head up,
03:12
and I saw her face, said hello,
03:14
and then I immediately noticed something
03:17
across the bridge of her nose,
03:18
a crease in her skin.
03:20
In medicine, we call that crease the allergic salute.
03:22
It's usually seen among children
who have chronic allergies.
03:25
It comes from chronically rubbing
one's nose up and down,
03:28
trying to get rid of those allergy symptoms,
03:31
and yet, here was Veronica, a grown woman,
03:33
with the same telltale sign of allergies.
03:35
A few minutes later, in asking
Veronica some questions,
03:38
and examining her and listening to her,
03:41
I said, "Veronica, I think I know what you have.
03:43
I think you have chronic allergies,
03:46
and I think you have migraine
headaches and some sinus congestion,
03:48
and I think all of those are
related to where you live."
03:50
She looked a little bit relieved,
03:53
because for the first time, she had a diagnosis,
03:55
but I said, "Veronica, now let's
talk about your treatment.
03:57
We're going to order some
medications for your symptoms,
03:59
but I also want to refer you to
a specialist, if that's okay."
04:03
Now, specialists are a little hard to find
04:06
in South Central Los Angeles,
04:09
so she gave me this look, like, "Really?"
04:11
And I said, "Veronica, actually,
the specialist I'm talking about
04:13
is someone I call a community health worker,
04:16
someone who, if it's okay with you,
04:18
can come to your home
04:20
and try to understand what's going on
04:21
with those water leaks and that mold,
04:22
trying to help you manage those conditions in your housing that I think are causing your symptoms,
04:24
and if required, that specialist might refer you
04:28
to another specialist that we
call a public interest lawyer,
04:30
because it might be that your landlord
04:32
isn't making the fixes he's required to make."
04:34
Veronica came back in a few months later.
04:37
She agreed to all of those treatment plans.
04:39
She told us that her symptoms
had improved by 90 percent.
04:42
She was spending more time at work
04:45
and with her family and less time
04:47
shuttling back and forth between
the emergency rooms of Los Angeles.
04:49
Veronica had improved remarkably.
04:54
Her sons, one of whom had asthma,
04:56
were no longer as sick as they used to be.
04:58
She had gotten better, and not coincidentally,
05:00
Veronica's home was better too.
05:02
What was it about this different approach we tried
05:06
that led to better care,
05:08
fewer visits to the E.R., better health?
05:11
Well, quite simply, it started with that question:
05:15
"Veronica, where do you live?"
05:17
But more importantly, it was that we put in place
05:20
a system that allowed us to routinely ask questions
05:22
to Veronica and hundreds more like her
05:25
about the conditions that mattered
05:27
in her community, about where health,
05:29
and unfortunately sometimes illness, do begin
05:31
in places like South L.A.
05:34
In that community, substandard housing
05:35
and food insecurity are the major conditions
05:38
that we as a clinic had to be aware of,
05:39
but in other communities it could be
05:41
transportation barriers, obesity,
05:43
access to parks, gun violence.
05:45
The important thing is, we put in place a system
05:48
that worked,
05:50
and it's an approach that I call an upstream approach.
05:52
It's a term many of you are familiar with.
05:54
It comes from a parable that's very common
05:56
in the public health community.
05:58
This is a parable of three friends.
06:00
Imagine that you're one of these three friends
06:03
who come to a river.
06:05
It's a beautiful scene, but it's
shattered by the cries of a child,
06:07
and actually several children,
in need of rescue in the water.
06:10
So you do hopefully what everybody would do.
06:13
You jump right in along with your friends.
06:15
The first friend says, I'm going to rescue those
06:17
who are about to drown,
06:18
those at most risk of falling over the waterfall.
06:20
The second friends says,
I'm going to build a raft.
06:22
I'm going to make sure that fewer people
06:24
need to end up at the waterfall's edge.
06:25
Let's usher more people to safety
06:27
by building this raft,
06:28
coordinating those branches together.
06:29
Over time, they're successful, but not really,
06:31
as much as they want to be.
06:34
More people slip through, and they finally look up
06:35
and they see that their third friend
06:37
is nowhere to be seen.
06:38
They finally spot her.
06:39
She's in the water. She's swimming away from them
06:41
upstream, rescuing children as she goes,
06:43
and they shout to her, "Where are you going?
06:45
There are children here to save."
06:47
And she says back,
06:48
"I'm going to find out
06:50
who or what is throwing these children in the water."
06:51
In healthcare, we have that first friend —
06:55
we have the specialist,
06:58
we have the trauma surgeon, the ICU nurse,
06:59
the E.R. doctors.
07:01
We have those people that are vital rescuers,
07:02
people you want to be there
when you're in dire straits.
07:05
We also know that we have the second friend —
07:08
we have that raft-builder.
07:11
That's the primary care clinician,
07:12
people on the care team who are there
07:14
to manage your chronic conditions,
07:16
your diabetes, your hypertension,
07:18
there to give you your annual checkups,
07:19
there to make sure your vaccines are up to date,
07:21
but also there to make sure that you have
07:23
a raft to sit on and usher yourself to safety.
07:25
But while that's also vital and very necessary,
07:28
what we're missing is that third friend.
07:30
We don't have enough of that upstreamist.
07:32
The upstreamists are the health care professionals
07:34
who know that health does begin
07:36
where we live and work and play,
07:38
but beyond that awareness, is able to mobilize
07:40
the resources to create the system
07:42
in their clinics and in their hospitals
07:45
that really does start to approach that,
07:46
to connect people to the resources they need
07:50
outside the four walls of the clinic.
07:52
Now you might ask, and it's
a very obvious question
07:54
that a lot of colleagues in medicine ask:
07:56
"Doctors and nurses thinking
about transportation and housing?
07:59
Shouldn't we just provide pills and procedures
08:02
and just make sure we focus on the task at hand?"
08:04
Certainly, rescuing people at the water's edge
08:06
is important enough work.
08:09
Who has the time?
08:12
I would argue, though, that if we
were to use science as our guide,
08:13
that we would find an upstream
approach is absolutely necessary.
08:16
Scientists now know that
08:19
the living and working conditions that we all
08:21
are part of
08:23
have more than twice the impact on our health
08:24
than does our genetic code,
08:27
and living and working conditions,
08:29
the structures of our environments,
08:30
the ways in which our social fabric is woven together,
08:32
and the impact those have on our behaviors,
08:35
all together, those have more than five times
08:37
the impact on our health
08:40
than do all the pills and procedures
08:41
administered by doctors and hospitals combined.
08:43
All together, living and working conditions
08:45
account for 60 percent of preventable death.
08:48
Let me give you an example of what this feels like.
08:52
Let's say there was a company, a tech startup
08:54
that came to you and said, "We have a great product.
08:56
It's going to lower your risk
of death from heart disease."
08:58
Now, you might be likely to invest
09:01
if that product was a drug or a device,
09:03
but what if that product was a park?
09:06
A study in the U.K.,
09:09
a landmark study that reviewed the records
09:10
of over 40 million residents in the U.K.,
09:12
looked at several variables,
09:16
controlled for a lot of factors, and found that
09:18
when trying to adjust the risk of heart disease,
09:20
one's exposure to green
space was a powerful influence.
09:24
The closer you were to green space,
09:27
to parks and trees,
09:29
the lower your chance of heart disease,
09:30
and that stayed true for rich and for poor.
09:32
That study illustrates what my friends in public health
09:35
often say these days:
09:37
that one's zip code matters more
09:39
than your genetic code.
09:41
We're also learning that zip code
09:42
is actually shaping our genetic code.
09:44
The science of epigenetics looks
at those molecular mechanisms,
09:46
those intricate ways in which
our DNA is literally shaped,
09:49
genes turned on and off
09:52
based on the exposures to the environment,
09:54
to where we live and to where we work.
09:56
So it's clear that these factors,
09:59
these upstream issues, do matter.
10:01
They matter to our health,
10:03
and therefore our healthcare professionals
should do something about it.
10:05
And yet, Veronica asked me
10:07
perhaps the most compelling question
10:09
I've been asked in a long time.
10:10
In that follow-up visit, she said,
10:11
"Why did none of my doctors
10:13
ask about my home before?
10:15
In those visits to the emergency room,
10:18
I had two CAT scans,
10:21
I had a needle placed in the lower part of my back
10:22
to collect spinal fluid,
10:24
I had nearly a dozen blood tests.
10:26
I went back and forth, I saw
all sorts of people in healthcare,
10:27
and no one asked about my home."
10:30
The honest answer is that in healthcare,
10:34
we often treat symptoms without addressing
10:36
the conditions that make you sick in the first place.
10:38
And there are many reasons for that, but the big three
10:41
are first, we don't pay for that.
10:43
In healthcare, we often pay
for volume and not value.
10:47
We pay doctors and hospitals usually
10:51
for the number of services they provide,
10:52
but not necessarily on how healthy they make you.
10:54
That leads to a second phenomenon that I call
10:58
the "don't ask, don't tell" approach
11:00
to upstream issues in healthcare.
11:01
We don't ask about where you
live and where you work,
11:04
because if there's a problem there,
11:06
we don't know what to tell you.
11:07
It's not that doctors don't know
these are important issues.
11:10
In a recent survey done in the U.S. among physicians,
11:13
over 1,000 physicians,
11:15
80 percent of them actually said that
11:16
they know that their patients' upstream problems
11:18
are as important as their health issues,
11:20
as their medical problems,
11:22
and yet despite that widespread awareness
11:24
of the importance of upstream issues,
11:26
only one in five doctors said they had
11:28
any sense of confidence to address those issues,
11:30
to improve health where it begins.
11:33
There's this gap between knowing
11:35
that patients' lives, the context
of where they live and work,
11:36
matters, and the ability to do something about it
11:39
in the systems in which we work.
11:42
This is a huge problem right now,
11:43
because it leads them to this next question, which is,
11:46
whose responsibility is it?
11:48
And that brings me to that third point,
11:49
that third answer to Veronica's compelling question.
11:51
Part of the reason that we have this conundrum
11:54
is because there are not nearly enough upstreamists
11:56
in the healthcare system.
12:00
There are not nearly enough of that third friend,
12:02
that person who is going to find out
12:04
who or what is throwing those kids in the water.
12:05
Now, there are many upstreamists,
12:08
and I've had the privilege of meeting many of them,
12:10
in Los Angeles and in other parts of the country
12:12
and around the world,
12:15
and it's important to note that upstreamists
12:17
sometimes are doctors, but they need not be.
12:19
They can be nurses, other clinicians,
12:22
care managers, social workers.
12:24
It's not so important what specific degree
12:26
upstreamists have at the end of their name.
12:28
What's more important is that they all seem
12:30
to share the same ability to implement a process
12:32
that transforms their assistance,
12:36
transforms the way they practice medicine.
12:38
That process is a quite simple process.
12:40
It's one, two and three.
12:42
First, they sit down and they say,
12:44
let's identify the clinical problem
12:46
among a certain set of patients.
12:48
Let's say, for instance,
12:49
let's try to help children
12:51
who are bouncing in and out of the hospital
12:53
with asthma.
12:55
After identifying the problem, they
then move on to that second step,
12:57
and they say, let's identify the root cause.
12:59
Now, a root cause analysis, in healthcare,
13:02
usually says, well, let's look at your genes,
13:06
let's look at how you're behaving.
13:07
Maybe you're not eating healthy enough.
13:10
Eat healthier.
13:12
It's a pretty simplistic
13:13
approach to root cause analyses.
13:14
It turns out, it doesn't really work
13:16
when we just limit ourselves that worldview.
13:17
The root cause analysis that an upstreamist brings
13:20
to the table is to say, let's look at the living
13:22
and the working conditions in your life.
13:24
Perhaps, for children with asthma,
13:27
it's what's happening in their home,
13:29
or perhaps they live close to a
freeway with major air pollution
13:31
that triggers their asthma.
13:34
And perhaps that's what we should
mobilize our resources to address,
13:36
because that third element,
that third part of the process,
13:38
is that next critical part of what upstreamists do.
13:41
They mobilize the resources to create a solution,
13:43
both within the clinical system,
13:45
and then by bringing in people from public health,
13:47
from other sectors, lawyers,
13:50
whoever is willing to play ball,
13:51
let's bring in to create a solution that makes sense,
13:53
to take those patients who
actually have clinical problems
13:55
and address their root causes together
13:58
by linking them to the resources you need.
14:00
It's clear to me that there are so many stories
14:02
of upstreamists who are doing remarkable things.
14:04
The problem is that there's just not
nearly enough of them out there.
14:07
By some estimates, we need one upstreamist
14:09
for every 20 to 30 clinicians
in the healthcare system.
14:12
In the U.S., for instance, that would mean
14:15
that we need 25,000 upstreamists
14:16
by the year 2020.
14:18
But we only have a few thousand upstreamists
out there right now, by all accounts,
14:22
and that's why, a few years ago, my colleagues and I
14:26
said, you know what, we need to train
14:28
and make more upstreamists.
14:30
So we decided to start an organization
14:32
called Health Begins,
14:34
and Health Begins simply does that:
14:36
We train upstreamists.
14:38
And there are a lot of measures
that we use for our success,
14:39
but the main thing that we're interested in
14:41
is making sure that we're changing
14:42
the sense of confidence,
14:44
that "don't ask, don't tell" metric among clinicians.
14:46
We're trying to make sure that clinicians,
14:48
and therefore their systems that they work in
14:50
have the ability, the confidence
14:52
to address the problems in the living
14:54
and working conditions in our lives.
14:57
We're seeing nearly a tripling
15:00
of that confidence in our work.
15:02
It's remarkable,
15:03
but I'll tell you the most compelling part
15:05
of what it means to be working
15:07
with upstreamists to gather them together.
15:08
What is most compelling is that every day,
15:13
every week, I hear stories just like Veronica's.
15:15
There are stories out there of Veronica
15:19
and many more like her,
15:21
people who are coming to the healthcare system
15:23
and getting a glimpse of what it feels like
15:25
to be part of something that works,
15:26
a health care system that stops
bouncing you back and forth
15:29
but actually improves your health,
15:31
listens to you who you are,
15:33
addresses the context of your life,
15:34
whether you're rich or poor or middle class.
15:37
These stories are compelling because
15:41
not only do they tell us that we're this close
15:43
to getting the healthcare system that we want,
15:45
but that there's something
that we can all do to get there.
15:47
Doctors and nurses can get better at asking
15:50
about the context of patients' lives,
15:52
not simply because it's better bedside manner,
15:54
but frankly, because it's a better standard of care.
15:56
Healthcare systems and payers
15:59
can start to bring in public health agencies
16:02
and departments and say,
16:04
let's look at our data together.
16:06
Let's see if we can discover some patterns
in our data about our patients' lives
16:07
and see if we can identify an upstream cause,
16:11
and then, as importantly, can we align the resources
16:13
to be able to address them?
16:16
Medical schools, nursing schools,
16:18
all sorts of health professional education programs
16:20
can help by training the
next generation of upstreamists.
16:22
We can also make sure that these schools
16:26
certify a backbone of the upstream approach,
16:27
and that's the community health worker.
16:31
We need many more of them
in the healthcare system
16:33
if we're truly going to have it be effective,
16:34
to move from a sickcare system
16:37
to a healthcare system.
16:38
But finally, and perhaps most importantly,
16:40
what do we do? What do we do as patients?
16:42
We can start by simply going to our doctors
16:44
and our nurses, to our clinics,
16:47
and asking, "Is there something in where I live
16:48
and where I work that I should be aware of?"
16:51
Are there barriers to health that I'm just not aware of,
16:53
and more importantly, if there are barriers
16:56
that I'm surfacing, if I'm coming to you
16:58
and I'm saying I think have a problem with
17:00
my apartment or at my workplace
17:02
or I don't have access to transportation,
17:04
or there's a park that's way too far,
17:06
so sorry doctor, I can't take your advice
17:08
to go and jog,
17:10
if those problems exist,
17:12
then doctor, are you willing to listen?
17:14
And what can we do together
17:17
to improve my health where it begins?
17:18
If we're all able to do this work,
17:21
doctors and healthcare systems,
17:23
payers, and all of us together,
17:25
we'll realize something about health.
17:27
Health is not just a personal
responsibility or phenomenon.
17:29
Health is a common good.
17:33
It comes from our personal investment in knowing
17:36
that our lives matter,
17:38
the context of where we live and where we work,
17:40
eat, and sleep, matter,
17:42
and that what we do for ourselves,
17:44
we also should do for those
17:46
whose living and working conditions
17:48
again, can be hard, if not harsh.
17:50
We can all invest in making sure that we improve
17:53
the allocation of resources upstream,
17:55
but at the same time work together
17:57
and show that we can move healthcare
17:59
upstream.
18:02
We can improve health where it begins.
18:04
Thank you.
18:07
(Applause)
18:09

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Rishi Manchanda - Physician
Rishi Manchanda is an "upstreamist." A physician and public health innovator, he aims to reinvigorate primary care by teaching doctors to think about—and treat—the social and environmental conditions that often underly sickness.

Why you should listen

For a decade, Rishi Manchanda has worked as a doctor in South Central Los Angeles, treating patients who live and work in harsh conditions. He has worked at the Venice Family Clinic, one of the largest free clinics in the United States. He was the first director of social medicine at the St. John’s Well Child and Family Center in Compton, where he and his team provided high quality primary care to low-income families in the area. Currently, he is the medical director of a veterans’ clinic within the Greater Los Angeles Healthcare System, which he refers to as an “intensive caring unit.” He tells the National Health Corps Services, “The moment when a patient switches from despair to hopefulness is the greatest part of my service.” 

Manchanda is the author of the TED Book The Upstream Doctors, in which he looks at how health begins at home and in the workplace, with the social and environmental factors of our everyday lives. He shows how the future of our healthcare system depends on “upstreamists,” the doctors, nurses and other healthcare practitioners who look for the root cause of illness rather than just treating the symptoms.

Manchanda is the president and founder of Health Begins, a social network that teaches and empowers clinicians to improve health where it begins—in patients’ home and work environments. He also founded RxDemocracy, a nonpartisan coalition created to register voters in healthcare clinics. He serves on the board of the National Physicians Alliance, as well as on the board of Physicians for Social Responsibility in Los Angeles.

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