The Heroism of Incremental Care
Incremental care, or the delivery of care over a longer span of time, can be as effective as more immediate primary care in emergency departments. Doctors in immediate health crisis situations can handle patients’ pressing problems, but long term incremental care delivered by primary care practitioners can increase general health rates, lower mortality and decrease hospitalization rates. By developing relationships with patients, primary care practitioners can encourage them to report problems earlier and deal with recurring issues with prior knowledge of the problem at hand. Incremental care focuses on the course of patients’ health over time, with understanding of the issue being provisional and the treatment constantly adjusted for success. Despite incremental care potentially costing more in the long term, in the shorter term it can help to diagnose and treat issues before they become critical. By taking into account the information on the patient’s internal health from lab results, the state of their living conditions, the state of their care (including medication and treatment) and information on patient behaviour such as sleep, stress and more, medical professionals can make much more informed decisions about treatment and care. In future, the introduction of wearable technology will provide constant health updates, making treatment even more personalised. However, incremental healthcare has yet to be recognised as a valid recipient of funding allocation, with the intervention style of care – found in orthopedics, cardiology, gastroenterology, dermatology and radiology – gaining the majority of payment. The lowest paid specialisms, such as family medicine, allergy/immunology, psychiatry, and HIV/infectious disease, along with palliative care, geriatrics, and headache specialisms, improve health over a long period of time through incremental care, but are just as valid. Despite the greatest causes of death being uncontrolled hypertension, or high blood pressure, incremental care which would be best suited to its treatment goes overlooked. The future of medicine will depend on the recognition of incremental care, and the reform of healthcare to ensure that health practices focus on the long term, rather than immediate fixes.
We devote vast resources to surgeons and the like, while starving the physicians whose steady, intimate care helps many more. Illustration by Todd St. John

By 2010, Bill Haynes had spent almost four decades under attack from the inside of his skull. He was fifty-seven years old, and he suffered from severe migraines that felt as if a drill were working behind his eyes, across his forehead, and down the back of his head and neck. They left him nauseated, causing him to vomit every half hour for up to eighteen hours. He’d spend a day and a half in bed, and then another day stumbling through sentences. The pain would gradually subside, but often not entirely. And after a few days a new attack would begin.

Haynes (I’ve changed his name, at his request) had his first migraine at the age of nineteen. It came on suddenly, while he was driving. He pulled over, opened the door, and threw up in someone’s yard. At first, the attacks were infrequent and lasted only a few hours. But by the time he was thirty, married, and working in construction management in London, where his family was from, they were coming weekly, usually on the weekends. A few years later, he began to get the attacks at work as well.

He saw all kinds of doctors—primary-care physicians, neurologists, psychiatrists—who told him what he already knew: he had chronic migraine headaches. And what little the doctors had to offer didn’t do him much good. Headaches rank among the most common reasons for doctor visits worldwide. A small number are due to secondary causes, such as a brain tumor, cerebral aneurysm, head injury, or infection. Most are tension headaches—diffuse, muscle-related head pain with a tightening, non-pulsating quality—that generally respond to analgesics, sleep, neck exercises, and time. Migraines afflict about ten per cent of people with headaches, but a much larger percentage of those who see doctors, because migraines are difficult to control.

Migraines are typically characterized by severe, disabling, recurrent attacks of pain confined to one side of the head, pulsating in quality and aggravated by routine physical activities. They can last for hours or days. Nausea and sensitivity to light or sound are common. They can be associated with an aura—visual distortions, sensory changes, or even speech and language disturbances that herald the onset of head pain.

Although the cause of migraines remains unknown, a number of treatments have been discovered that can either reduce their occurrence or alleviate them once they occur. Haynes tried them all. His wife also took him to a dentist who fitted him with a mouth guard. After seeing an advertisement, she got him an electrical device that he applied to his face for half an hour every day. She bought him hypnotism tapes, high-dosage vitamins, magnesium tablets, and herbal treatments. He tried everything enthusiastically, and occasionally a remedy would help for a brief period, but nothing made a lasting difference.

Finally, desperate for a change, he and his wife quit their jobs, rented out their house in London, and moved to a cottage in a rural village. The attacks eased for a few months. A local doctor who had migraines himself suggested that Haynes try the cocktail of medicines he used. That helped some, but the attacks continued. Haynes seesawed between good periods and bad. And without work he and his wife began to feel that they were vegetating.

On a trip to New York City, when he turned fifty, they decided they needed to make another big change. They sold everything and bought a bed-and-breakfast on Cape Cod. Their business thrived, but by the summer of 2010, when Haynes was in his late fifties, the headaches were, he said, “knocking me down like they never had before.” Doctors had told him that migraines diminish with age, but his stubbornly refused to do so. “During one of these attacks, I worked out that I’d spent two years in bed with a hot-water bottle around my head, and I began thinking about how to take my life,” he said. He had a new internist, though, and she recommended that he go to a Boston clinic that was dedicated to the treatment of headaches. He was willing to give it a try. But he wasn’t hopeful. How would a doctor there do anything different from all the others he’d seen?

That question interested me, too. I work at the hospital where the clinic is based. The John Graham Headache Center, as it’s called, has long had a reputation for helping people with especially difficult cases. Founded in the nineteen-fifties, it now delivers more than eight thousand consultations a year at several locations across eastern Massachusetts. Two years ago, I asked Elizabeth Loder, who’s in charge of the program, if I could join her at the clinic to see how she and her colleagues helped people whose problems had stumped so many others. I accompanied her for a day of patient visits, and that was when I met Haynes, who had been her patient for five years. I asked her whether he was the worst case she’d seen. He wasn’t even the worst case she’d seen that week, she said. She estimated that sixty per cent of the clinic’s patients suffer from daily, persistent headaches, and usually have for years.

In her examination room, with its white vinyl floor and sanitary-paper-covered examination table against the wall, the fluorescent overhead lights were turned off to avoid triggering migraines. The sole illumination came from a low-wattage table lamp and a desktop-computer screen. Sitting across from her first patient of the day, Loder, who is fifty-eight, was attentive and unhurried, dressed in plain black slacks and a freshly pressed white doctor’s coat, her auburn hair tucked into a bun. She projected both professional confidence and maternal concern. She had told me how she begins with new patients: “You ask them to tell the story of their headache and then you stay very quiet for a long time.”

The patient was a reticent twenty-nine-year-old nurse who had come to see Loder about the chronic daily headaches she’d been having since she was twelve. Loder typed as the woman spoke, like a journalist taking notes. She did not interrupt or comment, except to say, “Tell me more,” until the full story emerged. The nurse said that she enjoyed only three or four days a month without a throbbing headache. She’d tried a long list of medications, without success. The headaches had interfered with college, relationships, her job. She dreaded night shifts, since the headaches that came afterward were particularly awful.

“You can eat the one marshmallow right now, or, if you wait fifteen minutes, I’ll give you two marshmallows and swear you in as President of the United States.” Copy link to cartoon Copy link to cartoon Shop Shop

Loder gave a sympathetic shake of her head, and that was enough to win the woman’s confidence. The patient knew that she’d been heard by someone who understood the seriousness of her problem—a problem invisible to the naked eye, to blood tests, to biopsies, and to scans, and often not even believed by co-workers, family members, or, indeed, doctors.

She reviewed the woman’s records—all the medications she’d taken, all the tests she’d undergone—and did a brief examination. Then we came to the moment I’d been waiting for, the moment when I would see what made the clinic so effective. Would Loder diagnose a condition that had never been suspected? Would she suggest a treatment I’d never heard of? Would she have some special microvascular procedure she could perform that others couldn’t?