Tuesday, August 05, 2008

What does “patient-centered” mean?

A few years ago the Institute of Medicine (IOM) told us that health care was suddenly to become “patient-centered.” What did that mean? In my simple way of thinking health care had always been about taking care of patients. Good old fashioned doctoring. How could you be more patient centered than that? Respecting patients’ values and preferences was nothing new. Did the IOM have a loftier concept in mind? No one seemed to offer much of a definition, at least until now.

Yesterday Bob Wachter blogged about an ABIM forum on patient-centered care. Many anecdotes and viewpoints were shared, but I was most interested in Don Berwick’s definition of patient-centered care. Dr. Berwick, leader of the Institute for Healthcare Improvement (IHI), defined it thusly:

The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.

Berwick elaborated on the definition by espousing a model of extreme consumerism. Attacking the writings of Eliot Freidson (a sociologist who argued that doctors, because of their professional expertise, had a unique ability to judge their work and decisions) he said:

…Let me drive my stake into the ground firmly at one end of the range between the professionally dominant view of quality of health care and the consumerist view. My stake is far from Freidson’s definition. Indeed, I think it wrong for the profession of medicine, or the profession of nursing, or any other health care profession, for that matter, to ‘reserve to itself the authority to judge the quality of its work.’… For better or worse, I have come to believe that we – patients, families, clinicians, and the health care system as a whole—would all be far better off if we recalibrated our work such that professionals behaved with patients and families not as hosts in the care system, but as guests in their lives.

Well, that kind of thinking turns professionalism upside down and devalues scientific expertise. Berwick was pressed by a member of the audience: would he order a non-evidence based cardiac CT on a middle aged man just because he asked for it and wanted reassurance? He would.

According to Berwick’s notion I may not be very patient-centered. I won’t prescribe antibiotics to every patient with sniffles and a cough who demands them, I won’t order “total body scans” on all patients who ask for them and I won’t tolerate woo in mainstream healthcare just because the public wants it.

Berwick’s ideas are right out of the Postmodern Medicine playbook. Postmodernism in medicine was best articulated by JA Muir Gray’s Lancet paper from 9 years ago. Postmodern medicine, he wrote, distrusts science and legitimizes complementary and alternative medicine. In the postmodern view patient perception and preference trumps professional expertise, which it views as being “paternalistic.” (If this is the view of patient-centeredness the IOM adopts it’s no surprise that they advocate for non-evidence based alternative medicine).

The real problem with Berwicks’ remarks on patient-centeredness is that they don’t square with his speech at SHM 2008 in which he criticized the U.S. health care system for its inefficiency. He trotted out data from the Dartmouth Atlas Project to show how countries with single payer health systems in the developed world achieve comparable outcomes with less cost than the U.S. The reason? The U.S. consumers pay more to get more, but what they get is often ineffective and wasteful!

Has Berwick flip-flopped? More likely, he’s trying to have it both ways. Does he think the radical consumerism in the U.S., where patients want what they want when they want it, is compatible with single payer health? No wonder some call it Kool-Aid.


Joe S said...

I think Dr. Berwick addresses your concerns in the speech. He notes that the onus is on the provider to explain to the patient what is in their best interest and if it fails, "then we should seek to improve our messages, instructions,
educational processes, and dialogue"

Anonymous said...

In my humble opinion the consumerism movement is way overdue in health care. No other industry is able to charge for services that don't work and kill 250,000 people a year as a side effect of business as usual. Hiding behind the cloak of professionalism is going to end.