Smart Medicine Starts Upstream

In his review of Rishi Manchanda's The Upstream Doctors, Dr. Tom Bodenheimer explains what it means to practice upstream and why primary care providers have to do it.

By Tom Bodenheimer, M.D.

How many of us in primary care have patients with diabetes whose A1c won’t go below 10? We counsel them on healthy eating and physical activity. We use motivational interviewing to help them set realistic goals. We prescribe the right medications at the right dose. But the A1c doesn’t budge. We start to talk to our team members about our non-compliant patients. We have spent hundreds of hours with no results. 

Everyone reading this vignette knows the answer. The patients live in unsafe neighborhoods with little public transportation. They have nowhere to walk. They live in a food desert with one fast food franchise whose salad costs twice as much as the cheeseburger and doesn’t satisfy the hunger. The pharmacy is too far away and the waits are too long, so medication refills don’t get picked up. Could the hundreds of hours we spend on our patients be better spent trying to address the conditions that keep that A1c so high? And will it be many more hundreds of hours before the renal failure, the heart attack, and the stroke inevitably take place? 

Sure, but we’re too busy in primary care. We don’t have time for community engagement. We’re not even trained for that kind of work. Public health and community organizers should be doing it. Not us.
In the TED e-book The Upstream Doctors, author Rishi Manchanda tackles this problem.
The book begins with a parable. Three friends approach a river flowing toward a waterfall. A small child is in the water, struggling to stay afloat. The friends then see other children struggling in the water. They jump in to rescue the children, bringing them one by one to safety. But more children appear, and the friends are not able to save them all. One friend quickly focuses her rescue efforts on saving the children closest to the waterfall and in immediate peril. Another friend crafts branches into a makeshift life preserver to keep more kids afloat. Then, suddenly, one friend starts swimming upstream and the others yell “Come back, there are more children to save.” The upstream swimmer shouts back, “I’m going to stop whoever or whatever is throwing these children in the water.”
Manchanda points out that evidence-based medicine does not venture upstream. We are praised for following the evidence-based guidelines, but those guidelines do not tackle the sickness at its source. As a result, people with health problems that have upstream sources often suffer unnecessarily for months, even years.
So what can people working in primary care do to address the upstream conditions that prevent us from helping our patients? Manchanda continually faces this challenge as he cares for patients in the Homeless Patient-Aligned Care Team clinic in West Los Angeles’ VA hospital. He writes, “The upstreamist considers it her duty not only to prescribe a chemical remedy but also to tackle the sickness at its source.”
Manchanda makes the case that patient care is often better in clinics that routinely assess and improve the upstream social and environmental conditions that shape health outcomes. He also chronicles patients’ stories and his and other physicians’ journeys upstream, often against the current of modern medicine, to help them.
Manchanda estimates that we will need at least 24,000 upstreamists working in US health care by 2020 to achieve significant improvements. That means physicians, nurse practitioners, physician assistants, nurses, pharmacists, and other primary care clinicians who have the skills, tools, and responsibility to ensure that their clinics systematically and continuously perform three critical tasks:
  • Ask patients about the upstream conditions where they live, work, eat, and play and their concerns and capabilities related to these conditions.
  • Address upstream problems at patient and clinic population levels.
  • Build bridges with upstream actors to improve health where it begins using a data-driven approach.
At the end of the book, the author addresses practical ways to add upstreamist elements to primary care practices. These activities need to be prioritized, authorized, and promoted by physician leaders, but they do not need to be carried out by physicians. What are a few of the ideas to make the upstreamist approach a routine part of patient care?
  • Add questions to the medical history about unhealthy social conditions that may impact the patient’s problem. These questions should be developed based on input from community stakeholders, local data and the latest research on social determinants of health. 
  • Include actions to address these conditions in the patient’s care plan. 
  • Designate someone in the practice to work with community, housing, governmental, recreational, food, income support, and other organizations to help address those conditions in order to implement that part of the care plan. This person could also be a political advocate for better laws and regulations.
  • Hire people for the practice who have an upstreamist orientation. 
  • Integrate the upstreamist approach into clinic quality improvement protocols and tools like the electronic medical record, care management tracking tools, and geomapping software.
Smart medicine starts upstream.

Tom Bodenheimer is a general internist who spent 32 years in primary care practice in San Francisco's Mission District: ten years in community health centers and 22 years in private practice. He is currently a professor of family and community medicine at University of California, San Francisco. He is co-author of Improving Primary Care: Strategies and Tools for a Better Practice (McGraw-Hill, 2006) and the health policy textbook Understanding Health Policy, 5th edition (McGraw-Hill, 2008). He has written numerous health policy articles in New England Journal of Medicine, JAMA, and Annals of Internal Medicine.

To learn more about upstream care, go to and check out the tools and innovations that are helping a growing number of upstreamists improve care. 
The Upstream Doctors: Medical Innovators Track Sickness to Its Source by Rishi Manchanda is available at TED Books, on Kindle and Nook and in the iBookstore.

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Posted by Sonya Collins on Nov 21, 2013 11:40 AM America/New_York
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