Fire Fighting vs Putting Out Fires

By Allen Perkins, MD

Originally posted July 8, 2013

I’m sure by now you have read about the 19 fire fighters who died fighting the wildfire in Arizona. The fire was hot, large and the fire fighters, though well trained, were in the wrong place at the wrong time. Fire is a natural part of the American ecology, so why were the fire fighters in that wrong place? To reduce the possibility of damage to man-made structures. The National Park Service (an arm of the federal government) budgets one billion dollars a year to suppress and fight fires that threaten structures in the wild land-urban interface.  The reason people live at this interface is that the view from the bedroom is spectacular up until the fire comes roaring down the mountain. Of course, living 30 miles from the Gulf in hurricane alley, I can’t throw stones.

The firefighters who died were fire jumpers.They go where the fire isn’t and heroically  move the fire away from man made structures. They are not paid by the homeowner or even the homeowner’s insurance but by the feds.

People with complex illness are living at the equivalent of the wild land-urban interface, though with different perspectives. In the story about the fire in Colorado, the home owner describes the death of her house:

“These houses did not burn, they exploded,” she says. “It was like somebody set a bomb off in the interior. I mean, it wasn’t a case of the roof caught on fire and then the house burned. Unh-uh. They literally incinerated.”

In the complex illness-healthcare interface, that explosion rarely happens. Instead, the illness occurs slowly, insidiously, perhaps due to poor choices that occurred decades ago and we “fire fighters” jump in and try to put out the fire. Take congestive heart failure (CHF) as an example. Conventional wisdom used to be that someone with an ejection fraction of less than 20% would live for a year at best. Now, 14% of Medicare recipients have a diagnosis of CHF. They account for 44% of all Medicare costs (about $44,000 per patient annually). Based on the Seattle Heart Failure model, if we were to disqualify a 65-year-old man with bad CHF (ejection fraction of 10%) from Medicare, our cost would be nothing, and he would almost certainly be dead in two years (the explosion). If this man’s doctor places him on all the right medicines and he gets an implantable defibrillator placed, he is very likely (82%) to be alive at 2 years and really likely (63%) to be alive at 5 years.

In part because of the protection of the National Park Service, people seem very likely to rebuild following the loss of a house. Again, from the interview, the reporter asked about a neighbor’s house being rebuilt:

“They’re building the deck now, which will be fabulous,” Moore says. “My behind neighbors, they’re about to stucco their house. So it’s gonna turn back into the neighborhood again.”

In our patient with congestive heart failure, after we “put out the fire” we seem to forget that rebuilding is not an option. Let’s say we took our patient who turned 65 and did everything we could to “tune him up.” He felt great. However, he’s on some expensive drugs and when he hits the doughnut hole he thinks to himself “You know, they put this great machine in me that must be keeping my heart beating and making it better” (it isn’t, but then again, why do people build back in the forest?). “I’ll just stop taking these expensive pills and let the machine take over.”

When this happens, he is back to only having a 63% chance of being alive in a year and a 40% chance of being alive in 2 years. When he starts to feel bad, we don’t send in the fire jumpers. Instead, despite having $40,000 of taxpayer money implanted into his chest, we wait for him to show up in the Emergency Department and once again “turn on the hose” or in this case drain out the fluid with Lasix.

There is a better way, but it takes acknowledging that we have a vested interest in people’s health. The science of chronic illness prevention is poorly developed and needs to be much better funded. Inexpensive interventions known to be effective need to be not only encouraged but mandated and physicians need to be held accountable for patient compliance (see the chronic illness model for details). Last, we need to be able to acknowledge when the house is a loss, hard as it is to do.

So what we need to do is be more like the National Park Service. We know where the fires will be; let’s work on keeping the “house” as far away from the fire as possible. When the fire comes, let’s pay for “fire jumpers” to find the sick, rather than waiting for the sick to come to us. Lastly, though death is sad, it isn’t the enemy. Let’s figure out how we can talk about it in a meaningful way.

4 thoughts on “Fire Fighting vs Putting Out Fires

  1. I like the analogy. I am not sure pretty much get the “keep the houses as far away from the fire as possibDle” part, but the “fire jumpers” to find the sick is less apparent. Case managers? Home monitors? Disease registries? other? Can you be a bit more explicit on what this means. I am only peripherally involved in undergraduate education, occasional FP med students in the office, but appreciate your blog as a resource. Thanks.

  2. The analogy came to me as a result of the Camden experience with patients with complex illness that was outlined in Atul Gwande’s “Hot Spotters” article in the New Yorker. The answer to your question is “Yes;” to care for patients well with complex illness it takes all of the above. I would refer you to Dr Gwande’s article for ideas about how this care can (and should) occur. I would then refer you to the Camden Coalition’s website (http://www.camdenhealth.org/)

  3. Wouldn’t greater access to ‘virtual RNs/NPs/MDs/DOs’ via Facetime or whatever electronic video portal allow for more comprehensive coaching or deeper, persistent conversation throughout a patient’s management of an illness? Greater means of communication with fewer barriers, especially as technology becomes more ingrained in people’s lives as they age should help prevent some, if not most, fires from igniting.

    1. I could not agree more. There is a very interesting article in Health Affairs (Porter ME, Pabo EA, Lee TH. Redesigning primary care: a strategic vision to improve value by organizing around
      patients’ needs. Health Aff (Millwood). 2013;32(3)) that identifies resource needs to provide care in this way. My hope is that I will be alive when the redesign efforts come to fruition as they almost certainly will have to for us to survive as a country.

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