The American healthcare system is kind of a nightmare to navigate, in the best of times. These last 5 years have not been the best of times, to put it mildly. In my conversations with patients I frequently find myself giving advice about how to deal with that system, above and beyond accessing acupuncture through my practice, and I’ve come up with a framework for how to think about the larger system that I think will be helpful to share with a wider audience: the Pyramid of care.
When you hear the word pyramid you might be thinking of a scheme, but in this model we are talking about how our healthcare system is designed to deliver care, and also what kinds of care it’s not designed to deliver and how to access those kinds of care anyway. The foundational idea here is that the base levels of the pyramid, the biggest ones, are the kinds of preventative care that people can often do on their own or with minimal guidance. As we go up the pyramid the kind of interventions become more intense, with bigger life-saving potential but also greater side effects.
Levels of the pyramid
Let’s say, for the sake of simplicity, that there are four levels to this model. As the base level we have food, exercise, habits, and most common supplements. These are the things that we do every day, and while we might not see immediate change when we tinker with those things we do usually see beneficial changes over time. What we are eating, how we are moving, our mental state throughout our day, whether or not we are taking our vitamins and eating our proverbial Wheaties are the question here. It can be helpful to see a healthcare provider and chat with them if you are planning a major change in this area, and this can be a great place for a health coach or a nutritionist. If you are planning to do a really extreme diet, like true 24/7 keto, then we might go up a level and consult with a naturopath or nutritionist to make sure nothing bad happens.
Level two is where I usually live as acupuncturist. Here we have acupuncture, herbs, bodywork, more targeting supplements, and more specific elimination diets. These are interventions that are still low side-effect but do require specialized medical training to practice well. Herbal medicine in particular can be very powerful, and thus does have some risks of hurting people if the prescriber does not have adequate training. Always see a qualified and trained herbal practitioner, in general. However, herbal medicine is usually safe enough that hobbyists can tinker with things and not cause too many problems if they are staying in the scope of learning.
Level three is where we start to use pharmaceutical medicines. These medicines are powerful, and excellent at doing their very specific jobs. Because they are very strongly acting agents, they also carry more risk of side effects, and thus the people prescribing them need to be well-trained. Here we have MDs, DOs, Naturopaths, Nurse Practitioners, etc. Some of these providers, like naturopaths, will use level two strategies first, and then level three if needed. In general the more time a provider gets to spend with a patient, the more likely they are to employ level one and two strategies first because they are able to see the lifestyle factors that play into a condition.
Level four is where we see surgical interventions. Surgery is a critical part of medicine where it is necessary. Obviously acute life-threatening injury lives here, but also chronic structural problems around the body can be resolved through good surgical care. However, if surgery is the first thing a provider suggests, they may be missing the possibility of a life invasive option farther down the pyramid that might be just as effective with fewer negative consequences.
I want to lay this out in this schematic way to make it clear that no categories are bad or wrong, but rather than they have different drawbacks. Every provider tends to think that their area is the right once, that their intervention is where everyone should start. That’s just the paradox of expertise at work; our perspective is colored by what we know, and it’s hard for us to see outside of that. A great deal of research has consistently suggested that team care offers the best outcomes to patients. Team care is a fancy way of saying that providers from different parts of the pyramid should collaborate on cases so that the best strategies from each area get used. This is great in theory, but the American healthcare system is not designed to provide this kind of care.
The American Healthcare Model
Our healthcare system is came into being from the late 19th to the mid-20th centuries. It was initially based on the French system, which came into being during Napoleonic wars. France under napoleon became a state that was mobilized in what political scientists call total war; every adult citizen was directly employed in the war effect as either a soldier or a support worker. The healthcare system emerged to treat war wounds and the effects of malnutrition amongst the population. It used a military command structure, with doctors as the generals at the top and nurses as the foot soldiers. This is how the US hospital system is organized, and it works well for a mass-casualty situation.
It is, however, not terribly well-suited to the everyday chronic things that Americans deal with. Primary care physicians end up being little more than referral-generating machines that do basic labs and exams, which many MDs and NPs find unfulfilling. Specialists are usually disconnected from the other providers, and patients end up confused about who they are supposed to be seeing and for what reason. The existence and validity of level one and two providers is often scoffed at by MDs, because they are trained to believe that if they don’t practice it then a kind of medicine is made up. They want to protect their patients from bad actors, which is a noble impulse, but it leaves patients surfing social media for advice about what supplements or diets to try or what herbs to consider. The easiest and most accessible interventions end up either never being used, or used with minimal expert guidance, and thus not having great outcomes.
What to do
If you have gotten this far in this article you may be feeling frustrated, which is fair. Our healthcare system doesn’t seem likely to improve in the next four years, at least in a top-down way. But the possibility of team care and its effectiveness remains, and my advice to you is this: assemble your own care team. Especially if you are living with a chronic injury or illness, you can be your own care coordinator. It’s dumb and you shouldn’t have to do it, but here we are. My basic recipe for you is to find 1 provider from each relevant category (you might not need a surgeon for example) that you like, through trial and error and recommendation. If you find a provider you really like, ask them who they like because they probably know good people. Bring the information from one provider to the other ones, and ask them what they think. Encourage them to talk to each other. Providers like feeling like they are solving a mystery, and we usually love to talk shop with each other.
How to work with me, the acupuncturist
Now that I’ve written a lot of words about the healthcare system from a thousand-foot perspective, let me come back to my specific role. As a level two provider I can handle some pretty acute illness or injury, as long as there is a level three provider in the mix, but I also really shine in cases where symptoms are chronic but not yet bad enough to qualify as a disease. Here is the world of nebulous, weird, inexplicable stuff that I love. This is basically preventative care; let’s stop your weird thing from becoming a disease! I see my acupuncturist once a month, just to deal with whatever annoying thing is happening and make it go away. Guess what; I’m very healthy. It’s not because I’m a higher moral being, it’s because I’m doing maintenance and preventative care. I used to be a patient with acute problems, and they were resolved mostly through acupuncture and herbal medicine, but occasionally other kinds of interventions. It was a long journey, and I had to advocate for myself quite a bit more than I should have needed to, but I got to the other side and so can you.
Take care out there, and remember that you deserve every good thing that this system of ours can be made to give you.
Comments