What Is an “Upstreamist” in Health Care?

There are three friends who come to a river,
and it’s a beautiful day, but that scene is pierced by the cries of people in the water
crying out for help, that they need a rescue. The three friends do what all of us do, especially
those in health care, and they jump right in to save those people — adults, children,
the elderly. The first friend, the strongest swimmer, says:
“I’m going to focus on those who are about to drown, those at the edge of the waterfall.” Everybody applauds that decision, and of course
it makes total sense to rescue those about to drown, and everybody doubles up and says:
“Let’s rescue.” People along the side of the riverbank say:
“Let’s invest more resources, give that rescuer what he or she needs.” But overtime, it becomes clear that that’s
insufficient; people slip through the grasp of the rescuer; clearly something else is
required. The second friend says: “To make this easier
and make our success rate go up, let’s coordinate the branches along the riverbank, and create
a raft, so we can usher more people to safety and prevent more people from going downstream
in need of rescue.” We all applaud that, and the success rate
goes up — fewer people are in need of downstream rescue with more people on the raft getting
ushered to the riverbank. And yet, in the course of that work, the first
friend and the second friend — the downstream rescuer and the raft builder — realize that
something is happening that they can’t fully articulate, but they see it every day. The people keep coming. The success rate, while better, still isn’t
as good as they would want. People slip through. They start getting tired, they start getting
a little jaded, and they start saying things to the people in the water like, “Why don’t
you know how to swim?” They start considering other rivers to jump
out into, leaving the purpose of rescuing. They start getting tired; but like a lot of
us, they remain doubly committed to the work, and heroically committed to rescuing, despite
this strange phenomenon. Finally, they realize that they came with
a third friend, and they don’t see that third friend. They finally spot her — she’s in the water. She’s rescuing people as she’s going,
but she’s swimming away from them, much further upstream. They shout to her: “Where are you going? There are people here to save!” They are in dismay. They are wondering why their third friend,
a vital part of their team, is now leaving them. Turns out, she’s not leaving them, she’s
actually in the water again, helping people as she’s going. She shouts back to them: “I’m going to
find out who or what is throwing these people in the water!” The reason I tell the story that way is because
in the American health care workforce, and the health care workforce in many parts of
the world, we know that we have that first trend. We have that downstream rescuer: the trauma
surgeon, the ICU nurse, the intensive case manager, the ER doctors, and the oncologists. These are people that are vital and necessary
parts of the workforce that we know we need. You want them when you’re in dire straits. We are now in the phase of that second friend;
the comprehensivist, the raft builder, the person who creates that primary care patient-centered
medical home to usher more people to safety, screen for certain issues, manage chronic
diseases, and makes sure that those who are at risk for disease are actually prevented
from becoming sicker. But we know increasingly now that while that’s
an important phenomenon in health care transformation in the US — the idea of a downstream rescuer
and the raft builder (primary care comprehensivist) — while we are in that phase, we know simply
by looking at our patients every day, that model of the health care workforce is necessary,
but insufficient. What we have in the health care workforce
right now — not nearly enough of, but what we do have certainly — is that third friend. We have the “upstreamist.” The job of the upstreamist is not to be the
hero nurse or hero doctor or hero community health worker, who is independently and individually
taking on rescuing people, but is instead, as many upstreamists before us have done,
thinking about how to systematically understand and address the social determinants of health
— where people live, where they work — and bring that understanding into the workforce
and the workflows of clinical medicine, of health care.

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