The title of the column, The Good Patient, is intended to be ironic.  People who follow orders often seem to be considered “good patients.”  My column, though, sees “good patients” as those who know what questions to ask and what steps to take  to get care that enables them to lead the lives they want.

He describes a problem in his right knee.  “The problem is osteoarthritis, it comes from medical error, from botched surgery when I was a medical student, aggravated by years of jogging.  In December 2004, in very bad knee pain, I was scheduled to have a total knee replacement.  But at the very last minute, a few days before my surgery, an orthopedist, a third opinion actually, suggested trying a steroid injection in my knee.  My surgeon agreed to try, and here I am.”

“It’s five years later, and just one more steroid shot later, and I’m limping a little, I’m almost pain free, and I have my own knee still in place.  It’s not a perfect knee. I can’t jog even a single step.  I have to wear special orthotics.  When I hike I have to use poles to take some weight.  But here’s the important point.  I can skate ski.  I can skate ski all I want.  With a metal knee I probably couldn’t, because a metal knee can’t take the torque. . .”

“Next weekend I will be up there quiet [on the trail] leaning on my ski poles and watching a little red squirrel watching me.     What health care do I want?  Well, of course what I want is safe, effective, evidence-based health care for my knee.  What do I really want?  I want to skate ski on that knee.  What I really, really want is five minutes  on a sun-filled blue sky 20-degree February afternoon in total silence leaning on my ski poles in that little stand of birches watching one busy red squirrel.  Now, I’m not saying I won’t need a metal knee some day, I probably will, but just not yet, not yet.  Health care wanted to give me a metal knee.  It was very ready to move, on a dime, and I wanted to visit a squirrel.  My care was dignified, it was professional, but it missed the point.”

Don Berwick, plenary speech “Squirrel,” IHI’s 21st National Forum, 08 December 2009.

“I’m going to bet nobody really wants a doctor visit or a blood test or a CT scan or a night in the hospital . . . You want Thanksgiving dinner with your family.  Or quiet time with your partner. . . Or a dive in the cool water.   Or to see that Van Gogh or hear that chorale one more time.. . . Health care has no intrinsic value at all.  None.   None.  Health does, joy does, peace does.  . . A health care system that gives us each what we really, really want . . . can be a system sustainable for our futures and for our children’s future.  It is different from the one we have . . . We just have to ask first, “What do we want?” . . . “When it comes to your health and health care, what do you want? . . .  What do you really want? . . .  What do you really, really want?”  Don Berwick, plenary speech “Squirrel,” IHI’s 21st National Forum, 08 December 2009.

Fact:  he does not believe in rationing.  “I cannot imagine that a civilized, developed country is actually going to deny highly effective and humane care to its people, that we’re going to say to Americans, ‘Too bad, medical science has something that can help you but you just can’t have it.’”  Don Berwick, plenary speech “Squirrel,” IHI’s 21st National Forum, 08 December 2009. 

He goes on to talk about both giving everyone the care they need and spending less to do it — a solution based on health care whose focus is, in my words, “to enable people to lead the lives they want.”

See Killer Cure:  Why health care is the second leading cause of death in America and how to ensure that it’s not yours.  Chapter Thirteen, “The Blind Men and the Elephant,” discusses twelve fixes for health care and why their failure to focus on the patient means that they can’t possibly succeed as planned today.