The Four Types of Patient Problems

Uncovering the building blocks of every clinical service

Recently, I sat in on a conversation challenging its participants to redesign a new health care system.  When discussing the topic of health care, the first word to follow is usually “problems.”  There are problem lists, patient problems, problem patients, doctor problems, problem doctors, supply problems, capacity problems, price problems, etc.  These conversations are challenging as they quickly devolve into a conflation of Primary Chaos health problems, the solving of which is the purpose of said system and Secondary Complexity payment and operations problems,  consequences of the current implementation of health care.  Scoping is crucial here, as literally everything in the universe could impact human health, so anything could be part of a health system.  Thus, for the purposes of focus, we are talking about problems for which individual people seek help. A health system, then, actively solves problems for individuals which we currently call patients, because they have to wait.  Let’s hold off on public or population health for now. 

In an attempt to rectify the Primary Chaos of care, let’s approach the most important product/service question: “What is the problem we are trying to solve?” with the four categories of individual problems.  If you have any additional categories, drop them in the comments so we can expand (and re-title) this piece (or we can argue over categorization, one of my least favorite corporate activities)! 

Type 1: Symptom-driven

“I used to be able to do something and I cannot” or “Something hurts” or “I have a new rash.” 

The essence of the problem is that your patient is worse than they used to be and is attempting to get back to baseline.  Symptom-driven problems are those most commonly initiated by patients, for those of you thinking about engagement and consumerism.  The clinical job to be done is a combination of diagnosis and treatment, never quite as sequential as television would have you believe. Step 1 is defining the desired outcome – what does better look like? As good as before? Some newly accepted worse-than-before-but-better-than-now? Perhaps a functional definition, like “I want to walk downstairs without pain” or “make the rash go away.” Rarely is it a biometric definition. Whatever the initial concern, failure to clarify and set expectations nearly guarantees service failure, even with marked clinical improvement.  Adding to the challenge, the definition of better has a tendency to shift over time, adding complexity to clinical work that can otherwise look formulaic from the outside.  

The purpose of diagnostics (questions, exams, labs, imaging, tissue studies) is to clarify the diagnosis and the purpose of treatment (exercises, medicines, procedures, behavior change) is to reach the functional goal.  Sometimes negative diagnostic studies can provide therapeutic relief, while failed therapies can suggest new diagnoses.  Very messy, never boring. And if all else fails, we have a tendency to blame it on the patient and just say you are making it up (or say its viral). 

Type 2: Enhanced function

“I want to run a marathon!”

The healthy patient who wants to be healthier. A wonderful problem to have, but one for which our current system is ill-designed.  In medicine, we are better at fixing than building, because our system is designed to balance risk and benefit in the pursuit of improving health, not merely improving health alone. All the education, training and licensing is intended to ensure that we stand between you and risky things that may hurt you but, in the right circumstances, might help you:  Medicines, radiation, surgeries you don’t need, etc. We are fundamentally risk managers, because risk without the possibility of benefit is intolerable harm. This might feel like a great limitation of our “sick care” system but not for bad reasons.  So when you go for marathon advice, you are likely to get injury prevention advice, or cardiac fitness risk stratification, or something else that takes the form of “something bad not happening,” which is not quite the same as the something good you want to do.  

Honestly though, if your doctor cannot run a marathon, why are you going to them for advice?  In general, these types of functional enhancements tend to be lower stakes (mortality-wise), with a longer time horizon and more routes to success.  Weight loss sort of lives in this category, and our tepid success (until GLP-1s?) is an example of our overall performance in this category. Sadly, because we are not equipped to really help these types of problems, we leave the door open for grifters, scam doctors offering usually very expensive and exotic treatments promising improvements.  A word to the wise– the road to success requires disciplined iteration with persistence through setbacks.  Be wary of anyone selling you a shortcut. 

Type 3: Administrative

“Sign this paperwork so I can get…:”

Some bureaucrat somewhere, at a job, government office, school or camp has decided that your doctor has to fill out some asinine paperwork so that you, the patient, can get what you need.  FMLA, Disability, parking permits, requests for different public housing, camp physicals, etc.  The justification for clinical involvement is pretty low, and generally amounts to someone else not having the courage to say “no” or wanting access to our malpractice insurance so if something goes wrong, we get blamed instead of the proximate cause/guilty party. As a result, these problems can feel adversarial in nature. Generally we treat these problems focusing on our own administrative efficiency and with annoying disregard for our poor patients and/or with suspicion that we are being conned.  The problem is upstream on this one, health care, usually primary care, just has to carry the burden so as to not abandon these folks entirely.  

Nevertheless, some of my biggest personal wins as a physician come from these problems, where we can use our significant influence for the benefit of a patient that really needs it.  For those in doubt on how to help, remember the Bill Taylor standard: write the most true, useful thing possible for your patients. “Ms. So-and-so informed me that she was ill on the date of her Dental Acceptance Test and has asked me to write a letter so that she can reschedule.”  It seems like a permission letter, but it is merely the statement two facts in conjunction that let’s the bureaucratic machine fill in what they need to get the job done.

Type 4: Preventive/Guideline-based

Preventive care problems are unique in that they are generated by health care guidelines rather than ever being perceived as problems by patients.  Primary prevention of disease, designing our systems to prevent disease before it starts, is the territory of public health.  Think safety belts, sewers, speed limits and the like.  

Secondary prevention, symbolized as the dreaded colonoscopy, is only possible when a condition has a prolonged asymptomatic phase, a reliable test for early detection, and effective treatment when discovered early. The leading organization here is the United States Preventive Services Task Force, an incredible group, with an incredibly challenging job and influencing policy for patients they will never meet.  Shout out to Dr. Krousel-Wood, my Dean at Tulane School of Public Health and Tropical Medicine! 

Tertiary prevention, the category under which chronic disease management falls, ensures the diseases you already have do not get worse, fall under this pattern as well. It is why you take medicine for conditions that may be asymptomatic (looking at you, hypertension). 

The challenge with these problems is they tend to be asymptomatic, or at least not high priority for patients relative to other life issues.  They often come with a burden– medicines to take that have side effects, uncomfortable or risky procedures, or simply just time taken away from the rest of life.  However, failure here results in endless Symptom-driven problems, the prevention of which is the sales pitch is made to patients.

To make matters more complicated, our well-intentioned Secondary Complexity payment system has tied rewards to clinician performance on these guidelines, so we have a financial incentive to get you to do things you maybe don’t want to do but should.  It isn’t nefarious, but certainly introduces the risk for an adversarial relationship.  At the very least, these types of problems rely on sales skills that clinicians may lack entirely.  

Great, now what?

Now let’s take a step back and think about these four types of problems when constructing a health care service.  They are all very different – presentation, risk from delay or failure, urgency, level of patient engagement, and form of resolution.  Nevertheless we currently subject everyone (patients and clinicians) to solving all four types of these problems at random, mingled together in a series of never ending, unsatisfying face-to-face meetings, which is just embarrassing.  As such, clinical services are hard to deliver and worse to experience.  We’ve evolved specialties by organ system as a way of coping with this chaos, but perhaps we ought to specialize by problem type. 

So as an aspiring (or current) deliverer of care, what should you do?  First, decide which of the four types of problems you plan to solve.  Differentiation is the key to scalable success, which is why there are no chain diners.  Although the problems can be interrelated, consider developing a service or at least a service line for each problem you would endeavor to solve.  For example, symptom-driven concerns require rapid access, with low barriers to entry.  The time required to solve these problems is variable and hard to predict in advance, implying open scheduling.  Think, solution shop type work using the language of Clay Christensen. Conversely, administrative problems are similar to value-added processes and can be managed and operated like any other production line. Guideline based is an entirely different service experience, likely best provided proactively instead of reactively.  There are many variables here– this is all to say it is best to consider the types of problems you are going to solve with your patients as you design your value creation service model as well as your value capturing business model to match the work to be done.  With these building blocks, we could build an entirely new service model of care, from the ground up.