sterbo

This is so common sense, so obvious in it's logic that while I wonder how it possibly could have taken us all this long to consider it as a reality, I am really so happy that we seemed to finally be poised on it's serious implementation...



Letting the Patient Call the Shots

• • By PAULINE W. CHEN, M.D.

Published: June 4, 2009
I would like to believe that my care is “patient-centered.” I try, for instance, to begin my visits with patients by asking how I can help. And I try not to leave an exam room without setting aside time for anything patients might feel I did not address.

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Donald Berwick



But a couple of weeks ago, Dr. Donald M. Berwick, made me wonder if I should do more.
Dr. Berwick, a Harvard pediatrician and president of the Institute for Healthcare Improvement in Cambridge, Mass., is a leading authority on health care quality. Last month in a national health policy journal, Dr. Berwick published an article titled, “What ’Patient-Centered’ Should Mean: Confessions of an Extremist.” In it, he writes that the United States will require health care systems that are radically different from most of the ones we have today if we are to deliver truly patient-centered care. These systems would transfer control from doctors to the patients themselves.
Some examples of this new model of care? Shared decision-making would be mandatory in all areas of care, with patient preference occasionally putting evidence-based care “in the back seat.” Patients and families would participate in the design of health care processes and services and would be a part of daily rounds. Medical records would belong not to clinicians but to patients, who would no longer have to get permission to look at them or call the doctor for lab results.
Even the word “compliance” would become obsolete.
As Dr. Berwick writes in his piece, “[We] would all be far better off if we professsionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives.”
I called Dr. Berwick recently to discuss his definition of patient-centered health care, the effect of such a system on doctors, and actions patients could take now to improve their care.
Q. Do you think “patient-centeredness” exists in current health care practice?
A. If you are interested in quality, you have to be interested in patient-centeredness. Good doctors and nurses do try mostly to focus on every patient as an individual. But we have built a system around clinicians that makes it impossible to customize care the way it needs to be. We don’t have a standard of services or processes that are comfortable for patients. We have built a technocratic castle, and when people come into it, they are intimidated.
Patients keep having to repeat their name because the system has no memory. We dress them in silly-looking gowns. We give them the food we make instead of the food they want. We don’t let them look into their medical records unless they have permission. Health care keeps telling patients the rules instead of asking patients about their individual needs. What is said is, “This is how we do things here,” not “How would you like things done?”
People get accustomed to this. They are trained to be passive, and passivity is not a good idea. Studies have shown that people who are trained to be proactive do better and feel stronger. They have more pride and trust in their own capabilities.
When you make someone helpless, in a funny way you make them sicker, even if all you cared about was just the body.
Q. What if a patient’s preference is in conflict with recommendations grounded in evidence-based medicine?
A. I would treat it as a challenge of information exchange. Human beings have got to have the ability and the responsibility to make their own decisions. As long as they know everything they need to know, they should be able to make the decision. If we doctors feel a person is going to make unwise choices, we have to take on the responsibility of being teachers, educators and informers. We need to give people all the knowledge and information so they can make their decisions well.
And we don’t do that well at the moment. It’s often done as a relatively pro forma matter.
Q. Tell me about your views on “noncompliance.”
A. I think “noncompliance” is a control word, a power word, and we need a slightly different one. “Compliance” means I order and you either do it or not; you obey. Patients live in their bodies and may know more than the person who prescribes or does their procedure. They may know better about what is going on in their body and about the optimization of their own life. I think people who aren’t taking their own medicine are telling us valuable information about their medications and their life, and we need to listen to them.
Q. Many clinicians already feel stretched to their limits. Will creating this kind of patient-centered health care system add to the stress on physicians?
A. When you are in a position of having to deny and exclude patients, it is draining on the spirit. I actually think the mode I am counseling would be more satisfying or joyous for caregivers. Not all of the time or always, but it would be a better place to be. You would be putting yourself at more of a level with the patient, as more of a peer. And you wouldn’t have to carry on as if you were mythical. Medicine is imperfect and doctors know that.
Q. What can patients do to encourage more patient-centered health care?
A. Know more about what’s happening to you. It stuns me that people don’t know what medicine they are taking. Know the name of your medicine and what it does to you. If you are getting a procedure done, know the procedure. Medicine is not nuclear physics. Most adults and kids can basically understand. There can be uncertainty in medicine, but if there’s mystery, something is wrong.
Speak up and be prepared. From research we know that patients who write down questions do better. Bring your digital recorder into the meeting so you can listen to the conversation several times after. Bring a companion along to be your sentinel, your advisor.
In the end, if you are being cared for by a doctor or nurse who doesn’t give you what you feel is choice or control, find someone else. But only if you want that. Some patients don’t want that and it’s a perfectly good choice, too.
Q. And doctors?
A. Remember why you went into this profession in the first place.
But the burden to change the system falls on the leaders, the stewards, the people who create the organizations where the workforce works. Doctors want to do their work in a patient-centered way; they really do. We have to fix the health care system so that it gives doctors the time to do the job they want to do.
Join the discussion on the Well blog, “Giving Patients What They Want.”


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Freedom_User

FUCK YEAH

Buzzby

I'm not a doctor, but I've done years of computer support. When someone had a problem they couldn't figure out, I was the one to call.

I go to a doctor under the assumption that he knows more about health, the human body, and disease processes than I do. I'm trying to imagine what it would have been like doing computer support if my clients, who hired me for my expertise, felt the need to second-guess me at every step. It would have made every visit three times as long (Which is OK. I bill by the hour. ) The results would have been no better, but I could have seen three clients in the time it took to see one.

It's obvious that patients need to have input into the process. It's important that doctors take the time to really listen to their patients, rather than acting as "body mechanics". Medical records should belong to the patient, not the doctor.

I just don't know how far this patient-centeredness should go before it's simply an exercise in political correctness. Many Americans would be glad for any kind of health care. There are 47 million of us who don't have any kind of health insurance. There are only so many doctors to go around. If we go to a policy that's going to take up more of a doctor's time with each patient, someone is going to lose out. Who? The poor, who else?

I think it's far more important that everyone have access to health care before we tweak the system to be more patient-friendly for those who can afford to take up more of a doctor's limited time.

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