Trying to figure out “patient-centered” care…

The first link from an email source of medical news reads, “better patient-centered care reduces mortality risk.”

It made me think, exactly what do they mean with this new verbiage, “patient-centered care?”

And so I learned.  Thank goodness, I think my care is indeed patient-centered, even though the terms patient- and family-centered are news to me.

Definition:

Patient-centered care is based on the preferences and needs of the individual. Supposedly, this is a new and innovative approach.

It’s core principles are as follows:

Dignity and Respect. Health care practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care.

Information Sharing. Health care practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Patients and families receive timely, complete, and accurate information in order to effectively participate in care and decision-making.

Participation. Patients and families are encouraged and supported in participating in care and decision-making at the level they choose.

Collaboration. Patients and families are also included on an institution-wide basis. Health care leaders collaborate with patients and families in policy and program development, implementation, and evaluation; in health care facility design; and in professional education, as well as in the delivery of care.

Although I and many other doctors in the real-world, have strongly opposed Dr Berwick’s notions on transforming American healthcare to a more socialized British-like system, many of the above tenets of patient-centered care is exactly how most good doctors practice medicine.

Let’s take the most prominent electrophysiology disease, atrial fibrillation as an example.

First, it is critical to hear the AF patient describe their symptoms.  Knowing the degree to which AF affects one’s life dictates much of the potential choices of treatment.  Further, it is critical to know the patient’s social and cultural needs, as this will help design the best approach.  Can a patient afford medicine, or time off from work for a procedure, for example?

Second, information sharing of AF treatments is time consuming.  In AF, not only are there specific differences in drugs or procedures, but their are entirely different global strategies of approaches to AF.  (Like “rate versus rhythm” control, for example.)  I start with option ‘A’ and proceed through option ‘D’ or even ‘E-F’ at times.  That’s a lot.

Third, my patients are asked which option seems best for them.  Always, there are options, and my job is to help patients pick the one they feel best about, even if it is different than mine.  Exception: (and an important one at that), I will not participate in any treatment that I deem to be not science-based or dangerous.  Period.  For example, I simply will not do an ablation for AF if it is no chance of working.  Or, I will not cardiovert a patient who wants to be in regular rhythm, but refuses the blood thinner, warfarin, as doing so is dangerous.  Stretching this notion outside the rhythm realm, I would not recommend a radiation-laden imaging study whose only indication was a patient’s wish.  

So if patient-centered care says patient’s wants trump common sense, that patient will have to seek out another doctor.

On patient collaboration with institutions…This is hard one for me to grasp.  So the AF patient, after seeing me, is supposed to mosey over to the hospital administration department and make suggestions to them on how best to construct health programs and facilities, or even more laughable, how to conduct professional education.   At my place, a patient has said, “Doc, I know my heart is Ok, because I made it through that jungle of a parking lot of yours.”  And since I aim to be a patient-centered doctor, collaboration is collaboration, so I will forward him down to the hospital vice-presidents office so they can collaborate about the parking (and while he is at, he can ask about the shortage of blueberry muffins in the cafeteria.)

Summary:

I am fairly sure this patient centered care notion is not much different than “good-doctoring.”   I hope my patients are “empowered” with information on different treatment options.

Maybe it is why I cannot run on time.  Doing patient-centered care does not lend itself to the brief office visit, in which allotted time with the patient has much competition, not the least of which is filling out the billing invoice, oops, I mean the medical record. It is a real tragedy that after spending many “patient-centered” minutes with an AF patient, if the number of bullets on the review of systems is not sufficiently complete (fail to check the box on a runny nose or elbow pain), than you are at risk of fraudulent billing.

When PhDs, MPHs and other like-minded academics get involved, complicated verbiage rises.  Just read some of the pedanticism here.

Really though, good doctoring will always be good doctoring.

Primarily, doctors desire a system in which to unleash the intelligent application of all that modern medicine has to offer for the patient.

JMM

For another doctor’s opinion on this same notion–a very encyclopedic one at that–check out Dr Gorski’s treatise.