Friday, June 5, 2009

Calling the Shots

A patient came in to see my medical partner recently with right -sided rib pain. There were no other serious symptoms or complaints. It was a simple muscle strain but she wanted a better answer. My partner re-examined her, did a breast exam, tried to open up to more possible diagnoses, but she couldn’t find any. The patient wanted more.

In an article in the NY Times by Pauline Chen, she interviews Dr. Donald M. Berwick, a Harvard pediatrician and president of the Institute for Healthcare Improvement in Cambridge, Mass., who is a supposed to be a leading authority in health care quality. In his opinion, the control of the medical system should be transferred from the doctor to the patient. He believes that patient preference is so important that we should occasionally put evidence-based care “in the back seat”. In fact, he believes families should be part of daily rounds at the hospital as well.
Dr. Chen asked him “What if a patient’s preference is in conflict with recommendations grounded in evidence-based medicine?” He responded that he would “treat it as a challenge of information exchange”. My medical partner laughed because she tried that and her exchange with her patient went nowhere.

Dr. Berwick is a pediatrician. I wonder if he would let a four-year old determine if he or she needs an ENT consult for an acute ear infection. Probably not. It is very hard for me to believe these “ivory tower” doctors when they come up with new theories on how to run the healthcare system. They are not in the trenches in rural America. They are not on the front lines of medicine. Instead, they wake up in the middle of the night and create a new term called “patient-centeredness” and now have to write an article on the subject.

Dr. Berwick believes patients are our peers. Really? Working together to solve a medical problem is not the same as being my professional peer. He goes on to recommend that a patient bring his “digital recorder into the meeting so he can listen to the conversation several times after”. I know many lawyers who would love all patients to do that.

He ends his interview by stating that “we have to fix the health care system so that it gives doctors the time to do the job they want to do”. Funny, nothing he recommends saves time or saves money or makes the job any easier. This begs the question: does Dr. Berwick actually see patients anymore and how many does he see? I called his office and it turns out that he does not. If fact, the person answering the phone states he hasn’t “in years”. Maybe it is time for him to get his hands dirty again?

I am all for radical thinking. I am okay with brainstorming on how to make our healthcare system better. I may not be the smartest doctor in the world but I do know that there still has to be some type of chain of command in this profession. Anarchy doesn’t work. That being said, it is my opinion that the best type of patient-physician interaction is when both people are focused and present in the exam room without external distractions (cell phones) or internal distractions (“I have so much paperwork to do!”). The best care comes out of those situations.

My medical partner ultimately recommended some ibuprofen and observation for her patient. My partner tried to reassure her patient as best as she could and suggested to give it a week and then have her return for a recheck. Paradoxically, if it was up to the patient, her care would be “centered” on having a CT scan or an MRI of the chest. It turns out that this would have cost thousands of precious dollars. Who is right in this scenario? Don’t ask Dr. Berwick. He is busy brainstorming.


Pat said...

One of your best essays, and damn funny, although it does give me pause. Perhaps in the ER I need to be more "patient-centered" when frequent fliers visit to get their chronic narcotics refilled. Do you think Dr. Berwick would give me a good character reference when my license gets yanked?

Medical Aesthetics Job Posting said...

I agree with the whole concept of information exchange;
but it’s absurd to suggest that the patient in question may have a better understanding of the process of their diagnosis.

The patient can only make sense of the symptoms, which may cloud their judgment in stating their need for pills or an MRI.

Your right, perhaps Dr. Berwick needs to get his hands dirty again to gain a little perspective.

Lymie said...

You are deliberately mis-interpreting what Don is saying. He is advocating treating patients like responsible adults, and really listening to them. Once you establish good relationships, and expectations of trust, the exchange of information and collaborative decision making becomes natural. If you are not smart enough to be able to explain the diagnosis and treatment options to your patients, because they are not your "peers" you have a serious problem. And you are seriously arrogant.

Most of what you jokers do in medicine is not evidence based, so more than one choice is viable. You can't force patients to accept treatment, either.

A lot of wasteful spending happens in the last two years of life. What Don advocates is for supporting home care, hospice, etc. It is doctors who hop on the train down intervention land, as part of for-profit medicine.

tantheman said...

Sorry for the late reply but just came across this post while investigating our whacked out CMS head. Just wanted to encourage you--don't let Lymie get to you. Clearly she/he is a delusional socialist along the lines of "I love Britain's healthcare" Berwick. Apparently Lymie is also psychic enough to figure out that you were deliberately misinterpreting him. I wish I had those skills. It would make patient care so much easier. And Lymie is the arrogant one--it's our fault that we're not smart enough to explain things to our patients? Of course it has nothing to do with the complexities of medicine and the fact that there are a lot of evidence gaps making the right decision sometimes not clear. Yeah, it's our fault. Oh, and you have to do all that and get a history and examine the patient and bill and write/dictate/chart your note and coordinate care and check all the health screening and address the 15 chronic medical problems and check all their meds and make sure they're not smoking and discuss diet all in 15 min.