Doctors
Know Best, but Doctors Sometimes Do NOT Know Best
—THE
NEW YORK TIMES, 2012
In current
clinical practice, providers focus on assessing disease severity and evaluating
drug and treatment effectiveness. There is less emphasis on patient involvement
in decisions about care or on the specific needs of patients that affect their
quality of life. Despite expensive, highly specialized, and technologically
advanced care practices; this disease-centered approach to care has resulted in
poor quality outcomes. In terms of research, knowledge gained from clinical
research does not directly answer the primary clinical questions of what is best
for the patient at hand.
Physician
centered practice developed from a system that allowed mounting utilization of
diagnostic testing, prescriptions, hospitalizations, and referrals without
regard for specific patient needs or desires. It is considered “depersonalized
medicine” or “illness- oriented care”, with the aim to treat the illness, not
the patients with the illness. The long held assumption that “Dr. knows best”
is now being challenged as payers and consumers demand better bang (better
outcomes) for the buck.
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Assumptions
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Provider Centered Care
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Patient Centered Care
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Disease focused
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Patient focused
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Physicians know best: the experts
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Physicians collaborate: the enablers
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Physician oriented outcomes: What
is best for the disease or illness
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Patient oriented outcomes: What
is best for individual patient
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The best intervention for the
typical patient
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The best intervention under
what conditions works for which patient
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Patients as passive: complying
with physician’s orders
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Patients as active: “Nothing
About Me Without Me”
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Patients voice is ignored
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Patient voice guides clinical
decision making
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“What’s the matter” with patients
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“What matters” to patients
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Fee for service, Shorter, more
frequent visits, less reimbursement
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A variety of qualified primary care
providers – including nurse practitioners
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Consumers unaware what
healthcare $$ buys
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Consumer informed – demanding
better deal
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Provider Centered Research
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Patients Centered Research
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Absolute efficacy
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Comparative effectiveness
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Homogeneity
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Heterogeneity
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Generality
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Individualizations
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Statistical significance
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“What matters” to patients
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“Nothing
About Me Without Me.”
--PATIENT'S VOICE
Consumers are demanding
that the role of the healthcare professional should change “from experts who
care for patients to enablers who support patients to make decisions.” Rapid
advances in technology create a forum for improved health literacy and
curiosity among the public. Health care consumers no longer are interested in
playing passive roles, but rather expect to be listened to, respected and
treated with dignity and earnestness. Published reports from regulatory
agencies call out the health care industry to either improve morbidity and
mortality or face consequences of limited reimbursement and penalties.
Comparative effectiveness research (CER) moves scholarship in a direction that
engages the population as partners, addressing diversity and creating
personalized approaches. A consumer movement advocates that patient-centered
care become a goal of most healthcare practitioners and researchers worldwide.
Effective partnership
with patients has been reported being associated with a large variety of
positive patient outcomes, such as adherence to treatment, improved health, and
satisfaction. Today, patient-centered care is thus termed as one of six
indicators of quality care. Patient-centered care requires more than a
respectful attitude toward patients, it requires personalized clinical interventions. It is not necessarily giving patients what they
want regardless of values or costs, but rather requires knowing the patient as
a person and engaging the patient as a partner in his or her own care.
Similarly, patient-oriented
research should not be based on the evaluation of medical interventions in the
average patient, but “on the identification of the best intervention for every
individual patient. Patient oriented research focuses on the study of
heterogeneity and places greater value on observations and exceptions-especially
as they occur in real life versus under experimental conditions”. The
outcome measures should shift from what are most important to the doctors to what
are most important to the patients. “A difference, to be a difference,
must make a difference”. The
Patient Centered Outcomes Research
Institute (PCORI)
is a corporation authorized under the Affordable Care Act of 2010 that incorporates
patient-centered principles in their goal.
Key drivers of this paradigm shift:
Personalized
medicine and tailored therapeutics;
Advances
in pharmacogenomics and technology;
Medical
costs forecasted to be 20% of GDP in 2020;
Pressing
shortage of primary care providers;
Growing
chronic conditions and increased medical complexity;
Affordable
Care Act- 16% of citizens uninsured
“Be Careful
Not To Assume”
--Légaré et al., 2010
Determining what
patients want does not require complex scales or sophisticated statistical
tests. Instead, providers
must move from “what’s the matter” with our patients to “what matters” to our
patients. Often what the patient craves
is a listening ear, compassionate interactions, access to information, and attention to their
care. Other factors such as level of
adherence to medication, degree of tolerance to an adverse effect, past
experience, and health objectives can have a decisive influence on the
patient’s preferences. When more engaged with care, patients and families can
help prevent drastic mistakes or oversights, such as identifying a wrong drug
or dose they get from the pharmacy or notifying a doctor about a strange
medication side effects.
Quality
Equals Reduced Cost, Better Outcomes and Patient Satisfaction
The National Quality Strategy (NQS) promotes
quality health care in which the needs of patients, families, and communities
guide the actions of all those who deliver and pay for care; there are three
broad aims: Better care; healthy people/healthy communities; and affordable care . To advance these aims, they propose
six priorities, of which “ensuring that each person and family is engaged as
partners in their care” is one that pertains to patient centeredness. This
priority is based on the latest research, input from a broad range of
stakeholders, and examples from around the country and has great potential for
rapidly improving health outcomes and increasing the effectiveness of care for
all populations.
Healthcare
Providers: "Nice, But Not Necessary"
Patients:
"That's What I'm Paying You For"
--NURS
7106-001
It is important
to explore tensions that lie between the margins of traditional medical models
and stakeholder engagement models. As patients advocate for better care,
providers may feel justified in taking a patriarchal stance given level of
education and training. There has to be a change in how health care providers
are educated in order to make this shift. Not only are schools of medicine and
nursing going to need to teach how to recognize and treat diseases but also
they are going to have to be innovative in their curriculum in order to teach
their students how to enable their patients.
Some patients
may expect the provider, who has the expertise, to take the lead in patient
care. This expectation is summed up by the idea of "that's what I'm paying
you for". If patients are to be taking charge of their own care, there
needs to be a change in expectations. Responsibility should be shared in
appropriate ways. The goals of the provider may be disparate from those of the
patient when there is a misalignment in worldviews between provider and
patient. A common challenge is one of respecting religious/cultural values. It
is important to honor the patient's wishes as part of providing evidence based
care.
There are myths
about patient-centered care models - such as it is more expensive, takes more
time, and really falls into that "nice but not necessary" category.
As more evidence accumulates, these myths will be challenged. However, time
constraints pose a real threat in the current environment. Patients or family
members may be afraid to request something of the provider because they feel
like they are rushed or the provider does not have time for them. Transparent
communication about the time constraints and the need to schedule multiple
appointments, using other team members as indicated, and prioritizing the
patient's concerns can occur up front and mitigate this tension.
Fundamentally, a
key challenge going forward will be the ability to demonstrate that positive
patient-centered outcomes correlate with positive general health outcomes. One
elephant in the room is reimbursement. Primary care provider (PCP) visits do
not generate high levels of reimbursement so providers compensate by seeing as
many patients as they can per day. Some would argue that to keep afloat until
the major stakeholders - insurance and CMS gets behind this—patient centered
care is not possible. New payment models are coming however –as soon as 2015
for patients with complex chronic conditions.
Patient-Centered
Care is NOT Only the Job of Nurses,
But Will
Transcend Across Disciplines.
--NURS
7106-001
Patient-centeredness
must transcend across disciplines. Achieving this level of collaboration poses
the greatest challenge. As care becomes more focused on populations, across the
episodes of care and including prevention, interdisciplinary team care will
become the norm and the entire team will need to partner with patients and
families. Not only will disciplines need
to be able to communicate better, but also specialties will need to be able to
communicate better with the primary care team. All will be challenged to
communicate differently in a patient-centric model.
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