Thursday, August 07, 2008

More food for thought (and healthy skepticism) on patient-centered care

As I was mulling over Don Berwick’s definition of patient-centered care there occurred to me a couple more problems with his model. First, most patients don’t want to be the clinical decision makers, at least according to this large study. Most patients want us to be a little paternalistic.

Second, patients’ participation in clinical decisions is meaningless and may be harmful if their choice is not properly informed. Even for the intelligent patient, the best case scenario, the process is tedious and time consuming as I once described here:

Consider these case examples. You are counselling your patient about upcoming knee replacement. You plan to give enoxeparin for DVT prophylaxis. How do you inform the patient? Sure, you know that it’s the right thing to do and all the experts recommend it, but the patient deserves evidence. So, you do a Pub Med search (or, somewhat more easily, consult a filtered resource such as Up To Date) and cull out the studies you critically appraise as valid and applicable to your patient. In order to advise your patient on the magnitude of benefit of the proposed treatment you look for, or calculate the absolute risk reduction (ARR) for the proposed treatment as well as the absolute risk increase (ARI) for bleeding. In order to translate this into language the patient can understand you then, from the absolute risk reduction for DVT and the absolute risk increase for bleeding, calculate the number needed to treat (NNT) and number needed to harm (NNH) respectively. You then have the discussion with the patient, modifying it as necessary to take into account any unique attributes of your patient which might increase bleeding risk. If the patient is to be discharged early after the surgery you must also provide information concerning the cost of continued enoxaparin at home, taking into account the patient’s financial condition and payer sources. Then you ask the patient and any concerned family members if they have questions, answer them as they arise, and document your discussion in the medical record. Time consuming, eh?

It may sound extreme but it’s the only way to apply Berwick’s model and still practice evidence based medicine.

1 comment:

Anonymous said...

Ha, Ha!!!! I'm a statistician and I never have had a doctor even capable of doing such basic calculations. The problem with evidence-based medicine is not the patients; I've been teaching stat to undergrads for 30 years, and, if you take the time, you can present virtually any basic statistical concept simply. The problem is the doctors who won't or can't take the training they need.

As for your claim that people want paternalism, not evidence-based medicine, I think they WANT their doctor to go thru that process, not do (what is usually the case from my experience) what they think their buddies are doing.