The Aperture Problem

One Christmas we noticed that Grandma had lost weight, and that she was struggling with fluid in her lungs. She was feisty and beloved, and she had led a life worth living. Now her trajectory was shifting, and the family had to figure out what came next.

Even with all of our advanced technology and systems, the work of caring for a patient like Grandma still falls on a family member. Grandpa had passed away twenty years earlier. Thankfully there was a lot of family support, but even so, most of the work fell to one person. My mother stepped up and became Grandma's partner in health.

Over the following months, Mom went with Grandma to her visits to listen, organize, and advocate with the doctors and nurses. She made the appointments. She picked up the medications. She kept watch after Grandma came home from the hospital, and she got her back to the hospital when something wasn't right. She dealt with the insurance company. Grandma had good insurance, but she couldn't drive, she was living with a family member, and her money was running short.

Somewhere along the line, Mom figured out why. An insurance salesperson had been calling Grandma and selling her life insurance policies. Five, to be accurate, draining her savings in her final years. Nobody clinical did anything wrong. There was simply no one from the health system present in the space between appointments, and everything that lived in that space fell to family.

Eventually Grandma passed away, and the family celebrated her life. The hours and minutes of those months were a mix of rewarding and hard. And in many ways the real work began after: the emotions, the memories, a funeral, the assets and possessions.

A lot of people of a certain age have navigated a version of this. Add kids and a career, and it's a lot. It is the unmet burden that healthcare places on families and individuals. Most of that burden is not clinical care. It is coordination. It is rides, paperwork, money, housing, and hard transitions. It craves a different kind of healthcare.

So here is the diagnosis. The foundations of our health system are built on trust and on preventing harm, and rightly so. We anchored everything to scope of practice and licensure as our north star. But that anchor comes with a flip side. Nearly everything in the American health system passes through one aperture: the patient's care team. It is where trust, diagnosis, treatment, payment, documentation, and legal authority all live.

That makes the care team's time the scarcest resource in healthcare. A study out of the University of Chicago put a number on it: a primary care physician would need 26.7 hours per day to deliver the guideline-recommended preventive, chronic, and acute care for a typical patient panel. Shift much of that work to a full care team and it still takes 9.3 hours, more than a workday. The system asks its choke point to do twenty-seven hours of work a day. Demand that can't fit through doesn't go away. It gets refused, and refused demand lands somewhere.

We have spent the last two decades building a halo of virtual work around that same aperture. Think of the app portals, the call centers, the population health outreach campaigns for things like cancer screening, the virtual visits and e-visits. These are the right resources. But because of trust and risk, they all stay anchored to the care team, and to the clinician in particular. Patient questions, care coordination, navigation, reassurance, follow-up, prevention: all of it anchors to the care team, and most of it ultimately funnels toward the face-to-face appointment.

The appointment is the one moment the system has the patient's full attention, so we load it with the system's agenda too. Vaccines due, screenings overdue, care gaps to close. Whatever healthcare wants to accomplish, the visit becomes the single bucket we put everything into.

Our EHRs reinforce that structure and have made it worse. The typical electronic health record is designed to maximize the care visit. It is structured as a deep-dive bucket. When the patient is in front of you for twenty minutes, usually ten for the clinician, the team dives fast and deep into that one person's current situation, takes care of the thing the patient came in for, maybe closes a care gap or two, then backs out of the chart, writes a few notes, signs, and dives into the next bucket. Structurally, healthcare is an assembly of shallow, episodic, reactive sick-care moments. We spend almost no time on the longer arc of a patient's health, their trajectory, their goals, or the non-clinical parts of their life.

Our problem is an aperture problem. We have a single point of failure, one choke point where we try to do everything for everyone.

And everything that can't fit through the aperture doesn't disappear. It lands on someone. In my family, it landed on my mom.