Wednesday, May 16, 2007

Patient-Centered Care-what does it mean?

If you ask patients or other physicians what " patient centered care" (PCC) means I believe you would hear comments like these:

"care in which the doctor places the patient and his/her interests first",
"the physician treats the patients with respect and dignity"
"it's putting the patient first,caring about the patient,treating the patient like you would like to be treated, respecting the patient's values"

These are actual quotes or paraphrases of answers I have heard for doctors and patients and friends.

The Institute of Medicine's definition captures some of this in the following;

"Providing care that is respectful of and responsive to individual patient preferences,needs and values and ensuring that patient values guide all clinical decisions."

Who could argue with that and would not that be a sufficient imperative and worthy objective?

Apparently that is not enough in the eyes of some medical policy wonks.

Authors from the "Quality Improvement Program of the Commonwealth Fund" have declared their " 7 attributes for primary care practices " are something that patients " will value highly".

Their article in the Archives of Internal Medicine describes the results of a survey which inquired about the degree to which their stipulated definition of PCC was incorporated into a set of primary practices that they sent survey questions..

Their comments section emphasize the poor showing in regard to two areas in particular which apparently have risen to issues of major importance: the development of patient registries and patient feedback surveys. We learn that, for example that the American Board of Internal Medicine now requires in their competency maintenance scheme that physicians show competence in patient registries development and survey feedback.

They conclude stating "physicians should be well positioned (once they get the right tools) to provide the services and care that patients want and have the right to expect"

"The right to expect patient surveys" ??
We have come quite a ways from the simple admonition in 1927 by Francis W. Peabody that; "the secret of the care of the patient is caring for the patient." No easy survey audit of that is available.

I think that is what this is all about.People who are making a career at least in part by being quality gurus and who strive to be the judges of quality care need to have "quality indicators" that are easily measurable.They thrive on the search for rules in a world of exceptions and quick and dirty ways to determine if someone else is practicing their version of quality care.

Patient surveys have suggested patients want their doctors to be through,caring, respectful,and I suggest patients could not care less if they are given a survey or are aware that there is a patient registry or if their physician uses a computer based decision making program.

Using electronic means to have real time updated information about your patient and about current medical knowledge and consensus recommendations is important and offers great promise as are workable, efficient office management techniques (appointment access , facilitating consultations and referrals and lab test followup etc.) but..

Measuring how good you are as a physician by asking if you do surveys and have a patient registry is specious. It is form over substance. It is also using words that have a general common sense meaning -patient centered- to mean a list of requirements made up by one or more groups of self appointed experts in quality that may or may not have any direct relationship to level of care or the level of patient satisfaction.

The ACGME and ABIM have "determined" that a key competency of internists involves during patient surveys. Where is the evidence that surveys about services received a)reflects what the recipient really wants or values b)has been linked to any meaningful changes in medical practice with associated outcome changes?

Some data may exist but it seems to be that ABIM and ACGME have adopted this feel-good position even without the solid evidence base of the evidence based medicine to which everyone is obligated to pledge allegiance in every medical publication. Interestingly, in this Archives article, the authors offer no evidence to the efficacy or safety of their proposal and simply quote "authorities" including themselves.

Physicians practiced patient centered medicine-in the sense of what people generally think such a term would mean-before there were computers, patient surveys and patient data bases and will continue to be practiced as long as the physician does in fact place the patient first and takes seriously his fiduciary duty to the individual patient. That duty will be harder and harder to fulfill the more guidelines,rules,P4P imperatives,quality newspeak and CMS directives impinge upon and exert a demoralizing control over medical practice.

4 comments:

Anonymous said...

It's actually "The secret of the care of the patient is in caring for the patient." -Francis Peabody

Good post, great blog - nice to see you going for this long. ;-)

james gaulte said...

Oops,thanks for pointing out the typo.Spell-check is not enough,sometimes you have to actually read what you write.

Vince Kuraitis said...

I understand your skepticism, given how physicians have been mistreated by payers in the past.

While the concept of "patient-centered care" sounds great, it only makes when compared against alternatives. Some of these that you might recognize include:
1) Disease-centered
2) Technology-centered
3) Drug-centered
4) Bed-centered
5) Procedure-centered

I wrote about these alternatives a few years ago at http://e-caremanagement.com/6_1_99.htm .

At best, a registry or a questionnaire is a means, not an end in and of itself. While I understand that you might focus on potential abuses, please also consider potential uses.

MedInformaticsMD said...

We learn that, for example that the American Board of Internal Medicine now requires in their competency maintenance scheme that physicians show competence in patient registries development and survey feedback.

They conclude stating "physicians should be well positioned (once they get the right tools) to provide the services and care that patients want and have the right to expect"


As a medical informaticist, this approaches the absurd, I'm sorry to say.

Biomedical registry development (which requires strong competencies in biomedical data modeling, controlled terminologies and other areas, with all the nuances and idiosyncrasies these activities entail) will not be a competency most physicians will want to, or need to, have.

See, for example, this story on how biomedical data modeling was severely farkled by the "experts." This story too.

It's bad enough that IT specialists often seem to think they can develop biomedical databases with input from clinicians.