“I just want you to know, I won’t have a colonoscopy”, my new patient said with some amount of fervor in his voice. “And I don’t want to take a lot of medications.”
I looked him straight in the eyes and said “This is America, you don’t have to do anything, and I work for you. My job is to help you know your options.”
He seemed to relax. I reflected on the words I had just uttered, yet another time – it is the way I often try to set the tone as a non-authoritarian, patient focused physician. “You don’t have to do anything”, of course, only applies to the patient. The doctor has to do a lot of things, like document a treatment or follow-up plan for Medicare patients with a BMI over 30, or provide computer generated patient education to a minimum percentage of patients, and achieve a certain percentage of e-prescriptions. And right about now, we are starting to see financial consequences if too many of our patients, like the man I had just met, don’t want to take the medications that can bring their blood pressures or blood sugars below certain targets.
My new patient illustrated plainly how impossible it is to be practicing both “evidence based” and “patient centered” medicine in a climate where doctors are held responsible for “outcomes” that are the result of patients exercising their free will.
Later, at home, I was reading The New England Journal of Medicine and came across a series of online posts about transforming healthcare. In one, Dr. Amy Compton-Phillips illustrates the way she feels healthcare has started to and must continue to evolve. She seems to think this nation will move “up, out” from “standardized, evidence based care” to “care driven by patient goals” very soon:
(Image credit: http://catalyst.nejm.org/care-redesigned-for-a-new-age/)
I wonder how likely it is that payers like Medicare and for profit health insurers will loosen their grip on doctors’ day to day adherence to practices that are proven or at least strongly believed to save them money and benefit the greatest number of people, and instead allow the premiums they collect to satisfy individual, idiosyncratic patient preferences. That would reduce them to conduits for money, and strip them of their powers as arbiters and enforcers of “best practices”.
In fact, I seem to remember that’s what insurance companies were like when I was a resident more than thirty years ago. That was when doctors were supposedly authoritarian and paternalistic. In Family Medicine, that was certainly not the case – we were trained to put our patients’ values and preferences first. And back then, we didn’t get “dinged” by authoritarian, paternalistic insurance companies if our patients exercised their rights and declined to follow our advice.
I hope Dr. Compton-Phillips is right, and that healthcare in this country finds its way up and out of this oxymoronic situation that certifies clinics as “Patient Centered Medical Homes”, yet punishes them when they respect their patients’ wishes.
A Country Doctor Writes: 
All I can say is, “yep!”
I have to humble disagree with fact that you can’t do both. In a recent article in Nov 11 issue JAMA “Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels.” Not surprisingly when you paid only the Physicians or only the patient there was no significant difference in lipid reductions from the control group. Only when you paid both the Physician and the Patient did you only get significant difference and that was only a slight reduction compared to the control group.
Your first impression might be to say; see you can’t get these patients to do it even if you pay them. My reply is that the fact that this study was even done amazes me. Patients have very different motivations and you must appeal to right ones to get them to respond. Because of doctors shortage and quite frankly lack of training this should be done through care teams where the education is done by someone else on the team. I work for P&G and we have done extensive research in what patients want with an interation with a Physician and that is not what they getting when they walk in to a typical doctor’s office. The healthcare system is not consumer centric for various reasons and we must change. Value Based care is not a complete answer but it does at least align the incentives.
What I wonder about is … do insurers, who seem to drive the “healthcare industry” in America, really think their protocols are working? If all this was working, wouldn’t healthcare costs be going down? Since healthcare costs continue to climb, is it not more likely that the entire purpose of the protocol is to increase costs – i.e., the money delivered unto the insurers?
It is certainly not GPs, therapists, and nurse practitioners who are getting rich. Nobody even wants to be a GP in America anymore, apparently. Between the regulations, the lousy working conditions, and the low pay it’s not worth it.
Adding layer after layer of protocol and administration has not improved Americans’ health at the population level. That, I think, is why so many people distrust the industry now. “If you are doing what is best for me why am I still so sick” kind of thing. The business of healthcare has overwhelmed the practice of medicine.
Ultimately, the most effective health interventions – for the lifestyle diseases that consume so high a proportion of our healthcare dollars – are not those delivered in the doctor’s office, but those accomplished by the patient at home. Unfortunately, we have history’s most lazy generations to contend with right now.
Also, there is a strong narrative, driven by pharmaceutical companies and their ubiquitous advertising, that only by prescribing you X medication can a doctor can help you with your [insert complaint here]. Very few people, I believe, make the connection between those expensive advertisements, the retail cost of the drugs, the subsidy offered by insurance, and the subsequent inevitable increase in the insurance premium; and they certainly don’t connect the dots between the medication protocol, the tacit discouragement from pursuing lifestyle changes that would manage the condition, and the all-too-common a) later surgical procedure or b) lifetime commitment to a drug regimen.