The 4 Dimensions of Healthcare: How physicians can be more effective by paying more attention to TIME.

You may hear physicians talk about “standard medical treatments.” At least some standardization is essential, especially when dealing with variables in human healthcare and treatment options. When these standards are treated as guidelines, good physicians use them to help organize information for patients and show them when a deviation is required. When they’re treated as templates, however, that’s when problems occur.


In my work with treating spinal disorders, I find that I often must deviate from templated care. Unexpected circumstances, differences in lifestyle, physiology, morphology – there are too many variables from one patient to another to stick with a template. I’ve seen far too many cases where the guideline to fuse (for instance) overrides all other considerations. In these cases, surgeons appear to rely wholly on scans or X-rays only to confirm what they’ve already decided from the 10 minutes they spent talking to their patient.


Another reason I believe templated “standards” may be problematic is found in the fact that we have far too many spinal fusions in the U.S. I also believe that this leads us to conditions like “failed back surgery syndrome” (FBSS). This is symptomatic of a persistent error in how some medical practitioners treat their patients. They are missing essential facts about their patients that positively leads to complications years later.


The most significant cause of this error, I believe, is the way we treat time. Time is a common factor for all patients. It is a useful milestone that patients measure how long they’ve coped with a condition. It’s also a means for me to assess how to respond to a patient’s past and consider their future. Moreover, just as there are no two alike patients, no time is the same either.


In my work with patients from my practice in Beverly Hills, CA and ones I see from the Cedars-Sinai Institute of Spinal Disorders, I have found four distinct dimensions of time when treating patients with chronic neck and back pain. In fact, now I call them the “Four Dimensions Health.”


The first dimension is very personal for the patient. In fact, this dimension occupies time when the patient is not yet a patient, cataloging experiences like persistent pain somewhere along the spine, numbness and tingling in the arms or legs, and weakness. Eventually, the experiences culminate into actions, like purchasing over-the-counter medication, asking friends or family members for opinions, consulting the Web for medical information. When the experiences grow worse, the patient calls a physician for an appointment.


The second dimension is shared time between patient and physician, but no less personal. As the initial data collection begins, ongoing assessment is taking place. As the doctor gathers more information about family genetics, lifestyle choices, habits, hobbies, and occupation, the patient collects information about the physician by facial and verbal expressions, expertise and body language. At some point in this dimension, physician and patient make their initial assessment vis-à-vis a recommended course of treatment and a patient’s willingness to follow it. When patients come to me, I am acutely aware how deeply personal the experience is for them. That’s why I spend no less than an hour with my patients looking for insight into their condition. It is clinically proven that the freer the flow of information is between patient and physician, the better the treatment outcome.


The third dimension pulls together everything that physician and patient have learned about each other. We’re a team now. We spend whatever time necessary to assess physical examinations, X-rays, MRIs, and CT scans. I find that most of my patients are looking for my gut feelings about what to do next. Patients often open up more when we have the results of the physical examination and a scan in front of us as a talking point. That’s when I discover some details that we missed before.


For instance, if my patient is a golfer, she’ll tell me all about how she practices full swing and follow-through, day after day, that same movement, over and over. That tells me about the stresses on the vertebral structure and where discs may herniate and bone spurs may grow and compress nerves. Then in the middle of the conversation, I discover that this golfer spends hours a day on her cell phone. Habitual use of phones and other electronic devices forces us to tilt our head down and to the side, and hold a “reading position” for hours and hours a day. Now I’m looking at additional stresses that may accelerate herniation and trigger other problems. This is the kind of information that I need to form a complete my assessment of the patient’s health over time.


Still in the third dimension, patient and physician agree on a treatment solution which may, initially, include fitness programs, planned nutrition, supplements, and asymptomatic disease screening to rule out other potential medical issues. I will hold off surgery, even minimally invasive procedures, for as long as possible because I believe that the best outcomes come when we encourage the body to do its job of healing.


Most physicians stop here, which is reasonable in a template situation. Moreover, yet, care cannot end when the patient has left my office. The fourth dimension is my solo act, where my attention is urgently looking into my patient’s future, and how my recommended treatment corresponds with my patient’s long-term wellness.


There’s a bit of forecasting on my part, and sometimes it takes me close to the “heresy” of preventative medicine, which I’ll explain at another time, but the fourth dimension is mostly about extending care and anticipating WHEN my patient will need my help. I can’t predict everything, but I can be honest and let my patients know that the path to wellness is not accidental.  After all, movement is life.

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