An Interview with Director David Grubin and Executive Producer Jennifer Mieres, MD

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Director David Grubin interviews a physician on the way to a house call in rural Maine.

Rx: The Quiet Revolution showcases four different health centers that represent a monumental shift in the way that U.S. health care is delivered and how doctors and patients relate to one another. The film was the brainchild of cardiologist Jennifer Mieres, MD who runs the Office of Community and Public Health at the Northshore-LIJ health system. Dr. Mieres was the film’s executive producer, along with David Grubin, who also served as director, writer, and producer. Grubin drew on his own experience of growing up with a father who was general practitioner and an integral member of the community.

Q: Where did the idea for this film come from?

Jennifer Mieres, MD

Jennifer Mieres, MD

Jennifer Mieres: In 2011, the US Surgeon General had just released the first ever National Prevention Strategy and it coincided with my leaving NYU and coming back to the North Shore-LIJ health system to come up with strategies to improve the health of diverse communities. As a nation we are focused on great diagnostic strategies, we have great drugs, we have all sorts of great treatment strategies. But when you consider that 85 percent of health care outcomes depend on all of the things that we do as people outside of the health care setting, there’s a big gap. So I had the idea for a film that would capture examples of true patient-centered, person-centered care. I thought it could change the whole health care conversation if we showed people they need to be empowered partners in their health. I thought David was the person to do it, so I sent him an email. We met, and he was intrigued, and we have been on this journey for the past four years.

Q: David, how did you approach this topic as a filmmaker?

David Grubin: Sometimes you dream up a film yourself and try to make it become a reality, but sometimes a film comes to you. When Jennifer came and talked to me about this film, I knew there was something in it for me that was special because my father was a doctor. I grew up with a doctor, who trained before World War II and was practicing in the 1950s and 60s. So I felt close to medicine, and I loved the idea that this film was going to be about solutions to the problems with our healthcare system. It wasn’t going to be another critique. It wasn’t going to be about Obamacare, and it wasn’t going to be about who pays. But at first, I didn’t really understand the things that Jennifer was talking about. When she explained the importance of the partnership between patient and health care provider and the idea of patient-centered care, they were just words to me. The great privilege of making documentary films is you get to go out and research in the field and fill in the blanks. So I was excited to have the chance to travel across the country and meet health professionals who could explain to me, through their practices, what Jennifer was talking about. Her ideas began to take on flesh and blood, which is what any filmmaker needs and what the film becomes. I discovered there was a revolution going on in American health care, but most Americans don’t know about it because it’s not the kind of thing that makes headlines like, for instance, genetic advances in treating disease. It’s a quiet revolution. But if we’re going to really confront chronic illness – and chronic illness devours 75 cents of every health care dollar – the medical paradigm has to shift. I met health care professionals all over the country who are already practicing a different kind of medicine who are connecting to their patients, which is what patient-centered medicine is really all about: building trust, intimacy, relationship. I realized that something fundamental was being left out of the health care debate: the human touch. In a health care system that is good at dealing with trauma and taking care of curable illness but is too often short on humanity, forging an intimate connection with the patient is revolutionary. Our film is a chance to make some noise about it and say, “Wait a minute, if health care is going to change in America, it’s not going to change from what’s happening up on top in Washington. Health care is already changing because of what is happening at the grass roots.”

Q: How did you choose the four centers that are featured in the film?

David: What happens when you research a film is that you get yourself into a human network. Jennifer and a team of top rate advisors put me in touch with health care professionals practicing patient-centered care. I got in touch with one, then another, and those two put me in touch with two more, and suddenly you’re in a network of people that all share the same philosophy, and are practicing it.

Jennifer: When David explained the details to me, that we needed to get a treatment together, we partnered with Dr. Andrew Ellner from Primary Care Progress in Harvard. Together we came up with a steering committee. There were about five of us trying to figure out, “Ok, who are the experts in this field?” So we put together an advisory group with the former US Surgeon General Richard Carmona, and other health care luminaries and thought leaders. Then David spent time speaking with each of them to get an idea of how to go about this, to find the places. The advisory group was instrumental in site selection. Of course, David was even more instrumental because when he did the research and called all of these sites, he got a feel for whether they were part of the quiet revolution in health care.

David: I visited lots of places. And then we narrowed down our selections by geography as well as by population and the kinds of medical practices, so that there would be variety in the film. We were in the East, in Maine; in the West, San Francisco; in the South, in Mississippi. We went to Alaska.

Q: Do you think the things these health centers are doing can be applied to the larger population?

Jennifer: I would say yes. I spoke at Grand rounds for general medicine at NYU recently and highlighted the Mississippi piece, and people were fascinated. There’s definitely a curiosity and a search for answers about how to empower people to be partners in their care. The four sites we chose have developed simple and innovative methods that are easily reproducible. The idea from Mississippi of using iPads to improve health literacy in the management of diabetes–the doctors at NYU were fascinated. Just reminding people how to take the medication, when they should take it, what are the correct levels, that went over well, a lot of interest. When you look at each site that we’ve chosen–you could learn from Mississippi in terms of managing chronic disease. You could learn from Alaska about the holistic approach and culturally appropriate customized care where people are training non-medical people to be health coaches and really be ambassadors for health. And then, especially, I think one of the most fascinating pieces is looking at what they did at On Lok, a sort of day care for elderly people.

David: I’ll just add to that by saying that it’s a philosophy. It’s a way of thinking. In other words, if you are asking the right question, if you’re saying “How do I, as a healthcare professional, find a way to partner with my patients so that they become accountable for their own health when they’re not with me? How do I do that?”, then you can find different ways to do it and it gets to be applicable to your own particular community. You have to begin by thinking that way rather than putting your own needs first. So if you’re a doctor, you have to be thinking “Hmm…maybe it’d be nice if when my patient makes an appointment for 9 am, I actually see him at 9 am rather than putting whatever I’m doing before him or her.” There are these little things that begin to make a huge difference. We all know as patients that we don’t like sitting around for an hour waiting for the doctor to arrive. Medical professionals have to hold up their part of the partnership. There needs to be respect and trust on both sides.

Q: The focus of the documentary is patient centered care, but the On Lok organization goes a bit beyond what we think of as medical care to an entire living situation for elderly people. Could you help make the connection between On Lok and patient-centered care?

David: Again, it begins with what the patient wants. The patients, in this case, elderly, frail people – What do they want? They do not want to go into nursing homes. They want to be independent. They want to live in their own homes. So if you begin by asking what the patient wants. And then you say, Hmm, how are we going to do that? You can up with a solution called On Lok. On Lok is very comprehensive as you say, and it’s patient-centered because it’s answering the needs of the patient.

Jennifer: To compliment what David is saying I think On Lok is sort of an extension, a holistic approach to person-centered, patient-centered care. If you think of health care holistically from cradle to grave, On Lok just takes us as we move into the seventh, eighth, ninth decades. There are unique challenges that we face at that age. By the time we are 80 or 90, we will have at least one chronic disease, and so maintaining it, getting the right medication schedule, doing the lifestyle changes are essential to prevent and control chronic disease. On Lok provides total health care, a total health and well being environment. One of the ladies who is featured in the Rx documentary, goes into day care. Her needs are met. She’s not really truly ill, but her chronic disease is definitely managed. It really extends to a sort of holistic approach to health and wellness.

Q: David, you were featured in the film as a narrator and also in front of the camera. How did that evolve? Did you know from the beginning that you would go that route?

David: Well, I’d never done that before in any film. I was hesitant at first, but I realized that this was a story that I really understood. By being in the film, I could reference my father. He was in that first generation of physicians to be using penicillin. That was a miracle drug for him. He couldn’t rely on the amazing medicines we have today, but what he did have was a truly intimate relationship with his patients. Trust, empathy, compassion – that’s what his practice was based on. And I realized that that is what most patients want from their doctor. The Dean of Hofstra North Shore LIJ medical school Lawrence Smith told me, “As a patient, you don’t know whether your doctor is a great rheumatologist or a great nephrologist but you do know whether he cares about you”. And I said to him, “So does that help with the healing?” He said, “Well yes because one thing is that they can follow your advice. They’ll trust you if they know you care”. There you have it – it’s the relationship, the partnership. My father had that piece. He didn’t have the other pieces – the miracle drugs and the modern technology, but he was closely connected to his patients. I realized I could use him as a frame of reference for the way medicine has changed. And so I decided to actually put myself into the documentary with the camera in my hand, filming, rather than as the traditional host speaking directly to the camera, because it defined me as a filmmaker.

Q: What do you hope people watching this film walk away with? Or what do you hope that they do with this information?

Jennifer: From my point of view, I want people to walk away feeling truly empowered to be partners in their health and wellness. By seeing the examples in the film, I hope it will help give them the courage, the drive, to change their health care attitudes and change their approach to health care. And really see it as a true partnership, just like Annie Ford did in Mississippi . Really getting people engaged in their own health care discussions, taking a little bit of accountability for their action, and seeing it as their responsibility to partner with their physician, with their medical team, and stop being passive and silent is really something I would like people to see. To recognize, that it is truly a partnership and they have to take some responsibility.

David: I’m going to add another element, which is that health care professionals also have to be accountable. And I think one thing that can come out of seeing this film is that patients will expect their health care professionals to partner with them, expect their doctor to be on time, expect their doctor to explain what the pill is rather than giving it to them and saying see you in three months. They will hold their doctors to a higher standard. And that will help to change the system, because people will say, “Wait a minute, I saw this film on television. I want my doctor to be accountable and I will be accountable too.”

Jennifer: Yes, it has to go both ways. I agree, 100 percent. We focus on diagnosis and prognosis because, for the past 100 years, up until 2010, that’s how we were trained. In medical school, you were considered smart if you could quickly come up with diagnosis. You have fundamental knowledge to make the diagnosis and to figure out the treatment strategies. But this expands it. We weren’t held accountable for the outcomes. You write a nice prescription, you send the person out, and say come back and see me in three months or six months. They come back and see us in six months with all these complications, and you realize they haven’t been taking their medication. I want the medical community, my colleagues to see it as our responsibility to spend time in this partnership to discuss and customize the care, share decision-making.

Q: Healthcare can be a rather dry subject. What was your approach to making this film interesting for viewers?

David: As far as filmmaking goes, it’s heck of a lot easier to make an exciting film about the emergency room or the operating theater than it is about someone who is being treated for diabetes. From what you see on television, you would think American medicine is about the operating room and emergency room. But the fact is most Americans are not receiving that kind of medical care. It’s great that we do it so well, but most people in America are dealing with chronic illnesses. So, part of the challenge of the filmmaking was to turn preventing and managing chronic illness into compelling television. And you begin to do that by finding wonderful characters – medical people engaged and passionate in the practice of medicine, and patients learning how to take responsibility for their own health.

Jennifer: What David did so beautifully was to make it so real, so engaging. I think that this film has the ability to really move the conversation in health care to the level it needs to be. We have approximately 133 million Americans with at least one chronic disease. And we know that 85 percent of the outcomes depend on how we live everyday, the things we do, the many different factors other than the actual medical care. I feel that it can really change the conversation to one where people are empowered.

Finding Solutions

With chronic disease on the rise, U.S. health care costs skyrocketing and the old model of medicine failing to provided solutions, many are calling for a 'patient-centered' approach to health care.