Tenet 3: Health 3.0 is about Both Exteriors AND Interiors.

It’s the holiday season. And the Thanksgiving holiday is upon us.

What is Thanksgiving to you?

You might respond by describing the home where you and your family get together every year. The turkey and many sides you consume. The charitable work you do that day.

Or you might talk about the warmth you feel in the home where you all gather. The guilt that comes up when you eat all that food. The gratitude that fills you when you donate your time to others in need.

The first set of descriptions is all about the exteriors of Thanksgiving. The second is all about the interiors.

So which of these ways of describing Thanksgiving — exteriors or interiors — is the “correct” one to you?

If I asked you to capture Thanksgiving by only talking about either its exteriors or interiors, you could separate it like I just did…but that would be kind of silly, wouldn’t it? There may be more emphasis on one side for you than the other. But I bet Thanksgiving to you is about the exteriors AND the interiors.

It’s not that one way is more correct than the other — it’s both!

So it is with health, and how we care for it.

Take you yourself, for instance. Your body is your exterior. If I record your blood pressure and heart rate, check your electrolytes, and run a CT scan of your belly, I’m measuring your exteriors.

And if I’m studying how tests performed on you would be different in a Midwest community hospital system versus a hospital in a Texas border town, I’m analyzing the exteriors of your health care.

But all those measurements and analyses tell me nothing about your interiors. They don’t tell me about your stress over losing your job. Your fear of cancer. Your strained relationship with your family.

And they don’t describe cultural differences of family, food, and customs in the Midwest versus that Texas border town. The interiors of health care.

Health and health care involve both exteriors AND interiors. Neither is more correct than the other. Neither can be reduced into the other. And they both matter.

I think I’m stating something that you would find self-evident. And yet much of our prescriptions lately to save health care have been so focused on its exteriors — without remotely the same level of depth applied to its interiors.

Health 1.0 didn’t really differentiate interiors from exteriors. Health 2.0 obsesses on exteriors (see EHRs, Obamacare and all its embedded acronyms) and pays lip service to interiors (see the gamification of Press Ganey HCAHPS scores).

Health 3.0 makes exteriors and interiors in health care explicit.

Sure, it’s no fun being sick and having to go to the hospital or see a doctor.

But think about it. For all the pressures on hospitals and doctors’ clinics brought about by the Affordable Care Act, is your inner experience in those hospitals and clinics any better? How do they make you feel? Are they spaces for healing — not just on the outside, but on the inside?

You might say, that’s not for my hospital or clinic to do — that’s for my church, my social group, or my meditation retreat.

Casino hotel magnate Steve Wynn has talked about what makes his hotels special. Forget, he says, the crystal chandeliers and the hand-woven carpets and the marble. It’s not a dealer talking to the blackjack player. It’s Annie talking to Mr. Jones. It’s a bellman driving five hours each way from Las Vegas to Los Angeles and back to deliver a medicine bag with insulin that an older couple forgot. It’s the hotel immediately putting up that bellman’s picture and story online and in the building. So that everyone else working there also feels like doing something special for someone and being seen for it.

If this insight is operational in a casino hotel, why shouldn’t it be operational in centers for healing?

The technocratic engineers behind Obamacare think metrics for exteriors delivers great health care. This itself is debatable. But metrics for the interiors of health care is an afterthought. And the few interior metrics we do employ, like pain scores, are so gamed as to become meaningless (not to mention potentially dangerous).

In his book Poverty and the Myths of Health Care Reform, the late Dr. Richard Cooper dismantles the notion that health care cost discrepancies have to do with heterogeneities in care, inefficiencies, waste, and fraud — as we’ve been told by the technocrats of the exteriors. No, the discrepancies have to do with poverty. More than anything else, poverty leads to relatively higher health care costs. And poverty has both exterior and interior determinants.

Moreover, we’ve learned that adverse childhood experiences involving abuse, neglect, and household dysfunction impact not only mental but physical health later in life. The ACE score is an interior metric that’s now being explicitly used in medical clinics. Treatment protocols involving social services and psychotherapies are being designed for patients at an early age based on the ACE score. That’s a Health 3.0 move.

Now, I’d like to make a distinction between metrics for the exteriors and interiors of health and metrics for grading health care itself. The former is certainly useful. The latter is fundamentally flawed.

You see, in health care we’re in the service business. The only metric that truly matters in grading the service business is how the customer is served. That metric is inherently built into the relationship between the customer and the servicer. These two parties, in direct connection with each other, are in the best position in the service business to weigh in on the metric.

The health care business should be no different. But it is. I’ll discuss why in the future.

I’ll end here with a story recently published in his cousin’s blog by a physician friend of mine. Daniel F. Craviotto, Jr., is an orthopedic surgeon in Santa Barbara, California. I know him because his essay, “A Doctor’s Declaration of Independence,” helped launch a movement called Let My Doctor Practice, with which I’m now involved.

Dan’s uncle Charlie served in World War II and fought in the Battle of the Bulge. Uncle Charlie also watched his good childhood friend being sent away to a Japanese internment camp during the war. That childhood friend of Uncle Charlie has been Dan’s patient. At 95, he always asks Dan the same question: How’s Charlie? He’s forgotten that Charlie’s passed away, but not their friendship…and not the way Dan’s treated him. As Dan writes,

And for the first time today I tell him, “You know my uncle shared these stories with me about you. About your family and the internment and how it wasn’t fair. How you were such a good friend to him and how they carted you off.” And this man, with tears rolling down his eyes, but still with a smile on his face, just looked at me and said, “What were we to do?” He reached his hand out and shook mine, told me he missed Charlie and my father, Danny, and he thanked me for taking care of him. What a sweet man. Dignified. Full of grace. Always a kind word. I love that guy.”

The relationship between Dan and his patient is the metric that matters the most. We all want to see and be seen. On the outside and on the inside. It heals us. And as Steve Wynn and Daniel Craviotto show us, revealing those unique stories of connection makes us better in service.

Ignore the interiors of health and health care, and we miss half the entire story.

We must not do that in Health 3.0.