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Thursday, May 12, 2016

Patient-centered care

My last post discussed the wide gulf between health care and the rest of the world in the area of customer service. To sum up what took over 1,000 words to express: Customer service in health care totally sucks because the system promotes that suckiness and does nothing to penalize docs who make people wait, ignore what they say, rush through visits, and over-charge for their care. We get what we pay for.

But shouldn't we judge the system for what it was built for: the quality of the care we give? Sure, the service is overwhelmed with serious suckitude, but that can be forgiven if we give good quality care for people, right?

Even if that was the case, there is no excuse for the lousy service people get from our system. The lack of respect we, as medical “professionals” show to our patients undermines the trust our profession requires. Why should people believe we care about their health when we don't care about them as people? Why should they respect us when we routinely disrespect them? No, the incredibly poor service we have all come to expect from hospitals and doctors is, and never should be overlooked or forgiven.

Still, I already wrote a post about that. Go back and read it if you missed it. This post isn't going anywhere. Now I want to cover the actual care we give, and how it too has moved away from the needs of the people it is supposedly for. The people question how much providers care (verb) mainly based on the (lousy) service they get. The care (noun) we give is all about the quality of the product purchased by whoever pays for that (be they third-party or the patients themselves). The real question I am asking here is not if this care is good or bad (the answer to that is, yes, it is good and bad), but whether it is patient-centered.

This should be a silly question, like asking if car-repair is car-centered. But it is clear that much of the high cost of care in our country is due to the huge number of unnecessary procedures, medications, hospitalizations, and services given to/done on people. Unnecessary care is, almost always, not patient-centered.

There are many reasons for unnecessary care, including:
Defensive care, where the provider knowingly does unnecessary things to protect themselves from perceived legal threat. For example, a baby in the ER with a fever will often get a chest X-ray and lab tests drawn. In my office, babies with fevers get a good history and physical. Labs and X-rays are only done when I am still not certain after the history and physical exam.
Protocol-driven care, where care is ordered because the provider is under the impression that they are being measured for a certain item of care. While this is sometimes appropriate, it is often either a bad guideline (such as checking cholesterol in low-risk populations, or doing prostate-specific antigen testing in men over 65), or a misinterpretation of the guidelines (such as doing mammography or colonoscopy in the elderly).
Profit-driven care, where the provider simply orders something because they can rationalize it and it is paid for. Once, in my previous practice, we got part ownership in some x-ray equipment. Very soon after getting this, we noticed that far more people with coughs were getting chest x-rays and far more people with knee pain were getting (you guessed it) knee films. Our care didn't improve, it simply got more expensive (and profitable). Other examples of this are the annual lab profiles many physicians order when their office owns lab equipment (despite a lack of evidence that they improve care).

Add to this the high percentage of office visits that are not necessary but are done because they are the physicians' only means of payment for care (about 75% when I last counted), and you get a glimpse of just how much care done in the U.S. is not necessary. This is the antithesis of patient-centered care:
• It is costly.
• It exposes the patient to risk from the procedures.
• It exposes them to the risk of over-diagnosis.
• It does nothing to actually help the patient.

So again I turn to my experience over the past 3 years in a practice where I am financially obligated to give the best care possible. What does good care look like? More specifically, is good care the same thing as patient-centered care?

I think the answer to the second is “mostly yes.” Most of the time the care I give looks toward what is best for people and not at other things. I say “mostly” because there are some circumstances in which the patient as a customer works against good care, and I feel significant pressure to keep the customer happy by giving lower-quality care. The main time this happens is when people demand antibiotics for conditions in which antibiotics don't help. Sinusitis, bronchitis, and most pharyngitis gets better without any medication, and giving antibiotics just raises risk of adverse reactions or drug-resistant bacteria. But people still believe antibiotics are wonder-drugs and are often impatient to get well. So where do I give in to them for the sake of keeping their business? It does happen. It always will happen to some degree. But I will state categorically that it happens much less in my current practice than it did in my old one, as I have much more time to educate people, and they don't feel nearly the pressure to walk out of my office with “something to show for it” (since access to me is easy).

So what is true patient-centered care? I think there are two main things that define patient-centeredness in care:

1. It is focused on decreasing the risk of problems.

The first question I ask when someone comes to my office with a complaint or problem is: “What are the most important things to rule out?” Someone with chest pain, for example, needs to be ruled-out for heart problems. This is usually done by listening to the story, but sometimes requires further testing.

The same criteria can be used for any testing or treatment. Does giving the medication decrease the person's risk, or does it increase it. Giving a statin drug to a 60 year-old diabetic who smokes is probably something that will lower their risk of death from heart attack or stroke. Giving that same drug to a 30 year-old who has no other risk factors (but has the exact same cholesterol profile) is likely to increase their risk of problems. All care needs to be ordered and explained from this perspective. I recommend flu shots to high-risk people, explaining that it makes it more likely they will be around in a year (to which one of my patients responded: “What if I only want 6 months?” Smart ass).

2. It is focused on improving quality of life.

Once bad stuff is ruled-out, the focus turns to the other reason people seek care: they want to feel better. Many times I've heard of people with knee pain who get an X-ray and are simply told it is “normal,” without any treatment for the pain itself (perhaps the doc thinks the X-ray is therapeutic?). I've heard other exasperated people tell of times they've been told that, despite significant distress, “nothing's wrong.” While I think often the doc is simply being clueless or socially inept, it raises an implied accusation that the person is making things up or wildly exaggerating. This is often taken as what it is: an insult.

Again, all testing and treatment needs to be oriented toward this question as well. Does the testing increase the ability to improve a person's quality of life? If it identifies risk or avenues of treatment, then it shouldn't be done. If a medication doesn't make a person feel better or, conversely, if it has significant side-effects, it shouldn't be given (unless it substantially reduces risk).

One of the main problems with the care given by many providers is that, even if these issues are considered they aren't discussed with the patient. This is a way in which my current situation greatly favors patient-centered care in that I have time to explain why we might want to use a medication with potential side-effects (or even risks) if it improves risk or quality of life enough. People are far more open to taking medications that they understand, but it is our job to explain this.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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