Monday, October 5, 2009

Why "patient centered" health care isn't the norm

If you aren't very familiar with medicine or have had few encounters with the U.S. health system, you may think that the concept of health care being "patient centered" is so incredibly obvious that it shouldn't need to be stated. After all, we wouldn't need health care if people didn't get sick, and the ultimate role of doctors, nurses, hospitals, clinics, and medical technologies is to either prevent patients from getting sick or to help them get well. Yet the term "patient centered" is actually a surprisingly new idea in a complex health care system that has long focused on treating discrete diseases and organ systems (e.g. the heart, the lungs, the kidneys, etc.) rather than whole patients.

When I did my medical training a decade ago, it often seemed to me that medical students were encouraged to depersonalize patients and not listen to their concerns. During my surgical and medical rotations, a patient with stomach pain became "the abdomen in room 6," and the patient with a rare or difficult-to-diagnose illness became a "great case." There was a distinct pecking order within the prestigious academic hospitals where I did my clinical rotations - attending physicians at the top, followed by fellows, residents, nurses, students and other trainees, and finally, at the very bottom, the patients themselves. We took for granted that on the basis of years of studying medicine, we knew what was best for patients, and the few who questioned whether our care was actually making their health better were quickly labeled as "difficult" or "non-compliant."

National patient safety advocate Sorrel King, whose one-year old daughter died in Johns Hopkins Children's Center due to preventable medical errors, writes in her poignant 2009 memoir Josie's Story that being in awe of the technical skills of her daughter's physicians made her reluctant to challenge questionable medical decisions until it was too late. One of the reforms that she and her foundation have encouraged hospitals to adopt is the development of rapid response teams that could be triggered by anyone in the medical hierarchy who had concerns about a patient's condition, including - and especially - patients and family members.

But you don't have to set foot inside a hospital to know that we have a long way to go to get to patient centered care. It's typical in most parts of the U.S. to have to wait months to consult a family doctor about a non-acute problem. When you finally arrive at the office, you often aren't ushered back to an examining room until half an hour or more after your scheduled appointment time, then have to wait some more to actually see the doctor, who may spend five minutes or less with you before he or she is racing off to the next patient. (I'm happy to say that not every practice I've worked at fits this description - for an example of how electronic medical records and "advanced access" scheduling can greatly reduce such inconveniences, see the website of the one of the premier primary care practices in the DC Metro area.)

In future posts, I'll write more about a few important topics that I've only touched on here: improving patient safety, shared decision making, and practice transformation, including the patient centered (there's that term again!) medical home.