Next month I will visit New York and will talk with several doctors and patients about the importance of human interaction in healthcare. So we will talk about patient engagement and patient-centered medicine. To prepare these visits I was surfing on the internet to read articles, research, stories of patients and physicians.
And then I found this wonderful film and website: The quiet revolution. A website and movie about trust, partnership, compassion and connection to improve healthcare.
These are parts of the website. Please read and be inspired.
One of the most important skills is listening. Patients are readily able to tell you what’s wrong with them if you just take a deep breath, pause and actually listen to what they have to say. – Lawrence Smith of Hofstra North Shore-LIJ School of Medicine
What defines patient-centered medicine?
Patient-centered medicine is a term that can be fuzzy and hard to pin down. It isn’t one thing, it is applied by different practitioners in different ways and complicating matters are competing terms such as integrative and person-centered medicine. Whatever you call it, there are three broad themes that run through this way of thinking about health care:
Patient-centered medicine acknowledges that the patient is a person and that their mind, culture, family, environment, financial situation and other factors all have important roles to play in health. It recognizes that the ultimate objective of medicine is not only to improve the patient’s physical health but their overall well-being. Because this approach is multidimensional, providers often work in teams to address the many factors that impact health. When someone visits a patient-centered clinic they may meet with a primary care doctor, mental health counselor, nutritionist, social worker and dentist. This team of health professionals is often referred to as the ‘patient-centered medical home’ even though the team members aren’t necessarily in one geographical location.
The patient is treated as an equal partner in their own healthcare and is allowed a voice in all decisions. Instead of acting as a final authority, the physician acts more as a guide, dispensing information and lending advice and support where needed. Communication is key here as the doctor must elicit the patient’s preferences, goals and values. In cases of terminal illness, the physician must respect the patient’s right to withdraw from treatment if the benefits do not clearly outweigh the costs to the patient’s dignity and well-being.
Continuity means that there is an on-going, personal relationship with a physician (or other primary care provider) who is familiar with the patient’s unique circumstances. Instead of seeing a doctor only when faced with acute illness the relationship is on-going. This also means that if the patient is unable to visit the doctor, the doctor will visit the patient in their own home.
How can physicians have access to the most technologically-advanced arsenal of treatments the world has ever known and still be falling behind in terms of cost, outcomes and patient satisfaction? There are a number of interrelated issues:
1) The healthcare system focuses on treating diseases, not people.
The medical knowledge we gained in the 20th century had very narrow goals: stop people from dying. It was focused on treating short bouts of illness caused by a specific disease often localized to a particular organ or organ system. However, the CDC estimates that over half of adults in the U.S. suffer from one or more chronic diseases that cannot be cured, only managed. The costs of treating these diseases now represents 75 percent of the $2 trillion in U.S. annual healthcare spending. While we will always need acute care, managing chronic illness requires a different mindset. Physicians must consider not only the physical disease, but psychological, cultural, and socioeconomic factors that contribute to the illness. It is no longer enough to simply treat the most pressing symptom and wait for the patient to return when the condition gets worse.
2) Our payment structure reinforces the focus on disease by rewarding procedures, not cheaper interventions like prevention or care coordination.
In the 1950s, 60s and into the 70s, primary care physicians were well respected members of the community and helped patients navigate and coordinate more specialized care. Children of this era remember having a family doctor who would attend to all of their family’s medical needs. However, as Forbes columnist Todd Hixon beautifully summarizes:
In the 1980s and 1990s, as the cost of healthcare became burdensome for corporate and government payers, the dynamic changed. The federal government and the insurance companies created a structure of procedures and payment rates for each. Procedures based on higher levels of training and technology received higher fees. The Feds and insurers tried to push down prices of procedures, but at the same time they rewarded advances in medical knowledge and technology, and the result was highly trained specialists were well paid for performing sophisticated procedures, and family doctors were squeezed.
With money flowing to specialists, primary care doctors were forced to see more and more patients and had less time to spend with any one patient. Unpaid services such as preventive care and care coordination quickly went out the window. With the lure of greater prestige and earning potential, medical students funnelled into specialties, creating a deficit of primary care doctors. Today, it isn’t unusual for patients to be shuttled from one specialist to another with no one looking at the bigger picture of the patient’s well-being.
3) Treatment decisions are influenced by money, not necessarily what is best for the patient.
The procedure-based payment structure rewards doctors for doing more, even when it might be better to do nothing. As Sanjaya Kumar and David Nash write in their groundbreaking 2011 book Demand Better: Revive Our Broken Healthcare System:
Our healthcare delivery system spends more than 700 billion of its 2.3 trillion in annual health spending on medical care that does nothing to improve a patient’s health…seven hundred billion dollars every year. And, most alarmingly all that ineffective treatment and harmful care represents one-third of tests, treatments and procedures that physicians perform.
It’s not that physicians are looking to waste resources or get rich, but as Kumar and Nash note:
[Our current reimbursement] system and our cultural values serve up a ready answer to physician uncertainty as to what tests and treatments to order for their patients: more is better. When evidence is incomplete or conflicting about when to use a particular procedure, surgery or diagnostic test…some physicians will treat more aggressively, especially if piecework reimbursement rewards that.
Unfortunately, only about 20 percent of clinical procedures have solid scientific evidence to back them up. This means in many case physicians are flying blind and under great economic pressure to do more, even when it doesn’t necessarily serve the patient’s needs. With an arsenal of government-approved treatments available, there is great temptation to do “something,” even when it might be better to simply watch and wait.
4) Patients’ preferences, goals and values are marginalized.
When the patient is reduced to a vehicle for disease, the doctor becomes the most important person in the healthcare process. This may work fine when medical decisions are straightforward. But when there is ambiguity, a patient’s preferences, goals and values are essential in choosing the right course of action. The current culture of medicine (in addition to the economic incentives mentioned above) doesn’t encourage this kind of two-way communication. As Dutch social scientist Jozien Bensing notes:
…the discussion about norms and values inherent in every clinical judgment and decision seem to shift from the doctor’s consultation room to the conference room of the doctor’s professional association. If intentionally or unconsciously physicians do not want to negotiate with their patient about the usefulness of certain interventions, they can refer to the opinion of their professional association that is codiﬁed in guidelines and protocols instead, thereby shifting the responsibility for clinical decisions from a personal decision to a professional group decision.
All too often, the patient buys into the mindset that decisions about their health are best left to doctors. They become passive recipients, rather than active participants in their own care. This may have been acceptable when the aim of medicine was simply to keep people alive, but chronic conditions, in particular, require the patient to play a larger role in managing their own health.
Adding fuel to the fire is a rising tide of chronic illness. A glut of cheap calories in the American diet and a lack of daily activity have led to a dramatic increase in obesity and its associated conditions such as diabetes and heart disease, particularly in the last 30 years. Meanwhile, the Baby Boom generation, which represents a quarter of the U.S. population, is beginning to hit retirement age. This is a period of life when we become more vulnerable to illness and chronic conditions tend to accumulate.
As we’ve seen, the disease-based and doctor-centered medicine that brought us so far in the 20th century isn’t well equipped to mitigate and manage this growing tide of chronic disease. A new paradigm is needed that treats the whole patient and establishes a more balanced relationship between doctors and their patients.
Please watch the video. This inspirational video seems to be a personal tribute to the producer/writer David Grubin’s father, who was a practicing physician during the 1950s. The basic premise is that there is a new breed of healthcare professionals quietly spreading across the world who embody the values and commitment of previous generations of healthcare workers.