Can we save patient-centered care?

anna quindlen patient-centered care“Do you know who I am?”

I’ve always been a fan of the Pulitzer-prize winning author Anna Quindlen, and last week I ran across the text from an address she gave to a roomful of doctors and medical students at the Association of American Medical Colleges in November. (Note: the full text will only be available through this link until January 31, 2014.)

A mother and DES daughter, Ms. Quindlen describes herself as “medically adept.” She has also dealt with the illness, injury and deaths of both her parents. She is an intelligent, educated, motivated health care consumer, or “citizen-patient” as she was introduced to the medical audience.

At that meeting, with her usual insight and eloquence, she shared personal health care stories—some good, some bad—and entreated the doctors and future doctors in the room to never lose the ability to make “a human connection” with their patients.

It may seem counterintuitive, but at the time of a technological explosion, that human touch is more necessary than ever before.

When she asked her doctors, “Do you know who I am?”, it was not the arrogance of a celebrated writer, but an appeal from a patient to be “seen, acknowledged, [and] respected” by her care providers.

Impersonal medicine

Ms. Quindlen recognizes that “mass and instant communication” and the “information revolution” have affected health care, as well as her own profession of journalism.

The problems in health care, in patients feeling separate, ignored, patronized by doctors and nurses and other professionals—they are not stand alone problems. They’re part of something larger, more pervasive, more systemic in our society.

The only reason for a newspaper to exist is if readers feel that it provides something more, something deeper, something that will make them think…in a way they may not have done before.

Isn’t that why a patient might be just as happy to have someone listen to her heart at Walmart? If the care she’s been receiving feels perfunctory, impersonal, if she feels as though her doctor’s office is a place where no one knows her name, why not just swap it for a cheaper place where no one knows her name—and she can pick up tee shirts for the kids at the same time. You only need to see the doctor or the nurse in the family practice if somehow they provide more, different, better. If they provide that human contact we all crave.

Insurance-centered, not patient-centered, care

Ms. Quidlen’s sentiments resonated with me. I’ve thought for many years that patient-doctor relationships are falling away, and patients are rapidly becoming little more than bits of data (age, gender, weight, height, etc.) to be put into a computer so that a generic care plan can be spat out.

This is the age of one-size-fits-all “clinical guidelines.”

But I think Ms. Quindlen was preaching to the choir. Doctors want to practice personalized, patient-centered care. The for-profit business of medicine—controlled by the insurance companies, the hospital CEOs, and the federal government (Medicare, Medicaid, and now Obamacare)—however, is making physician autonomy a thing of the past.

I’m always happy to read about doctors pushing back against “cookbook medicine” and the unreasonable time constraints being placed on them (if you want to see a doctor explode, ask about electronic health records and “meaningful use”), but will they be able to push hard enough?

We will argue that guidelines and the principles that underlie their promulgation serve many “stakeholders” quite well, but they do a great disservice to patients and the 21st-century ethic that demands a patient-physician dialogue that promotes informed decision-making.

Progress in ethically driven medical care has ground to a standstill because physicians, insurers, economists, governments, pharmaceutical companies, medical device companies, hospital executives and other stakeholders currently determine the menu of diagnostic and therapeutic options by more mechanisms than just Clinical Practice Guidelines. By virtue of various indemnity schemes, including Medicare, the choice of menu items is largely predetermined for any individual.

In other words, neither you nor your doctor is in charge of your medical care. And the advent of Obamacare has made insurance companies the de facto gatekeepers of our health. They hold the money, so they call the shots.

Other than making you feel invisible, what else goes wrong when your health care providers don’t know you, don’t have time to get to know you?

Mistakes happen. Unnecessary tests get ordered. And this kind of assembly-line health care absolutely will increase costs.

Do you feel your doctor knows who you are?

Or, like me for the past few years, have you been made to feel like a faceless cog in the health care machine?

We deserve better; we need patient-centered care. Our health depends on it.

Sláinte,

Frugal Nurse

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