Sunday, January 23, 2011

How To Make The Patient The Center Of Patient-Centered Care

There is increasing attention being paid to the patient-centered medial home (PCMH) as a way to re-focus medical care on outcomes that matter to patients (such as sick days, hospitalizations, death) and less on surrogate outcomes (such as blood sugar control, cholesterol levels, etc).  The PCMH is also expected to allow physicians (especially primary care physicians) to spend more time with patients--time for counseling, care coordination, discussion and education surrounding medical problems, etc.  At this point, the National Committee for Quality Assurance (NCQA) is the organization that accredits medical practices as fulfilling the principles of the PCMH.  However, a review of their principles shows that in order to qualify as a PMCH a practice must meet a number of expectations, most of which involved new or improved technology (electronic health records, e-prescribing, patient registries and databases, etc).  Although there are other expectations, and the technology expectations themselves have understandable reasons for existence, there is no discrete description of what a patient's experience in a PCMH should be like.

This morning, I saw this article from the American Medical Association's Journal of Ethics Virtual Mentor website.  It is a few years old, and predates the current push for the PCMH, but is worth noting because the principles listed here are key to truly patient-centered care.  If health care providers follow these 10 rules, patients will get better care that is truly focused on their needs--patients will actually be the center of care.

The 10 points are:
  1. Be on time. If you aren’t, apologize. If you know you’ll be late, notify the patient. Doing so tells the patient that you respect his or her time.
  2. Find a way to touch your patient; the simplest way to do this is to shake hands when you enter the exam room. Look the patient in the eye when you shake hands. Maintaining eye contact throughout the visit conveys sincerity and honesty.
  3. Be interested in what your patient is saying—she can tell if you are faking it. Cultivate curiosity about how this patient is different from other patients.
  4. Communicate. Lack of communication is the most common complaint patients have about their physicians. This does not just mean talking—it also means listening. Being an active listener and responding to patients and their families is a vital skill. Effective communication includes explaining tests and diagnoses with patients in plain English.
  5. Learn to appear relaxed and not in a hurry. In situations of illness or crisis an aura of calmness goes a long way. It shows patients that, at the moment, their care is more important to you than the next patient.
  6. Never refer to a patient by a diagnosis. Patients are individuals, not loci or hosts for disease. Do not tolerate others’ use of such terms; such usage reinforces a service-oriented culture and makes the patient-physician relationship less personal.
  7. Convey a sense of warmth. This can’t be done without smiling. Endeavoring sincerely to establish rapport with patients helps put them at ease.
  8. Be mindful of how often you interrupt. Studies have shown that the physician usually interrupts the patient less than 20 seconds into the patient’s side of the dialogue.
  9. The needs of the patient must come first. This means you have to put aside your own prejudices and biases to help the patient. This clinical encounter is for the benefit of the patient—not the physician.
  10. The "platinum rule" of medicine is: treat every patient the way you would want a member of your family treated. A twist on the “golden rule,” it is one of the best ways to be aware of the needs and fears of our patients.
More than just good principles of patient-centered care, these 10 rules are key to effective and successful medical care, period.  They allow physicians and patients to develop therapeutic relationships that will address the patient's health care needs.

Ever since medical school, I have carried with me a list of ten key rules on how a physician should practice--something I have previously blogged about.  The ten rules listed in this Virtual Mentor article will be companions to those first ten.  They will remind me (and the students I teach) of the most important part of patient care: caring for the patient.

Tuesday, January 18, 2011

Do You Have Any Guns In The Home?

If this Florida legislator has his way, asking that question could cost up to $5 million and/or 5 years in prison.  I presume this is at least in part a result of the recent calls for increased gun control in light of the shootings in Arizona just over a week ago.

The legislator who introduced the bill has built his argument upon his worries that physicians who ask about guns in the home will report this to the insurance company, who could report them to the government, who then could come after your guns.  This argument is flawed: most docs who ask about guns do *not* report that to the insurance, and therefore the chain of feared consequences is never even begun.

So: why would physicians ask about guns in the home?  A few quick examples:
  • If there are children at home, a physician could ask about guns in order to discuss safety, accident avoidance and proper gun storage.  Evidence is clear that guns are much more likely to kill a family member than an intruder, so asking about gun safety and storage is a necessary part of well-child care.
  • If someone is suicidal or homicidal, the presence of a gun in the home increases the risk of completing a suicide attempt or severely harming (or killing) another person.  If a gun is available, then a mentally ill person has much more probability of hurting themselves or others, and a physician would be ethically and legally bound to approach that person's care more aggressively in order to avoid that harm.
  • If one person in household is being abused by another, the presence of a gun would increase the potential lethality of the situation.  A physician may need to know this information in order to provide the necessary guidance to the victim of abuse in order to see to their safety and protection.
Physicians have legitimate and necessary reasons for asking about the presence of guns in the home.  This law, as proposed, would severely undercut doctors' ability to care for their patients and could penalize what most would see as proper medical care, and would place more government controls on what can be discussed in the privacy of the doctor/patient interaction.

Let's hope this bill ends up in the trash pile, where it belongs.

Is There A Right To Health Care?

As part of an online community, a colleague presented this article to the group in order to further discussion and debate of the issues surrounding health care reform.  The article aims to discount claims that there is any sort of right to health care.

Not surprisingly to anyone who reads this blog, I disagree.  I'm posting my reply below.


This might not surprise anyone, but I find the article less than compelling.  If anything, the author has noted that England's approach to universal health care isn't idea, but he has not shot down the idea of universal health care overall.  In other countries (and in certain communities in our country), universal coverage is provided in ways that make health care available to all: there is England's national system, Canada's provincial systems, Switzerland (where everyone has coverage via an individual mandate and tight regulation of insurance company practices and profits--sound familiar?), Germany's combination of private/public coverage, Medicare (which dramatically changed the lives of elderly Americans), the Veteran Administration system (which some argue is among the best systems in America), etc.  The one question that can be fairly asked is how universal coverage should be paid for, but there are multiple arguments that the coverage can be provided.

From the standpoint of whether there is a right to health care, I don't think the article's author really, honestly addresses the question.  This is a complex question, and one that seems glossed over as the author moves on to attack the means of delivering universal care (as opposed to the perceived right to access care).

A few points:

  1. The rules of medical ethics can be used to argue that access to health care should be available to all: the principles of beneficence, non-maleficence, justice, and autonomy would suggest that a) access to care is good; b) lack of care is bad; c) it is unjust that some have access to care while others do not (often for reasons that are not in their own control); d) one cannot be a fully autonomous individual if one is not healthy.
  2. Religious guidelines can also be used in favor of the right to access: so much as religious faith compels one to help those less fortunate and to provide aid to the ailing, then faith can guide a right to health care.  The argument could be made whether such care should be provided in faith-based institutions, charitable organizations, or through government programs, but any faith that concerns itself with caring for the ill and the poor would have a hard time claiming that access to health care is not a right.
  3. Civil institutions can be used to argue for a right to health care: If we are seeking rights to "life, liberty, and pursuit of happiness", it is easy to argue that one cannot have any of the three if one does not have health as a necessary precondition.  The connection of health to life and the pursuit of happiness is clear, but is also applies to liberty.  How can anyone be an active citizen and take advantage of our cherished liberties if one is not in good health?
  4. Philosophical constructs exist that suggest that as individuals and as societies we should be working for the greatest good for the greatest number.  Kant's categorical imperative states that each of us should act in ways that we would like to see become universal law.  In this context, the argument I could make is that a)if we all agree that health care is a good thing, then b) we should seek to make health care available.  I think the argument could again be made as to the best way to reach that goal, but I think the goal itself can be easily agreed upon.
Regarding the author's question as to why a right to health care didn't exist in 250 BCE or 1750 AD, a quick answer could be this: in those years, medicine had fewer proven benefits and engaged in practices that actively caused harm (bloodletting, laudanum for anxiety, etc), whereas today's medical practice offers a much stronger balance of benefit vs. harm.  The argument could be made that increased access to medicine in the 1500s hurt more than it helped--maybe that is why societies did not seek to establish that harm.  Of course, in those years one could be enslaved and treated as chattel: maybe our society has advanced and moved forward to a more enlightened place?

Regarding other needs that the author addresses--food, shelter, clothing--many of us feel that there should be mechanisms to assure at least basic needs in all three areas.  Even if one does not feel that way, though, I would argue that good health is a necessary precondition for meeting these other three needs.  So in that perspective, health (and, by extension, access to health care) is a primary need for all.

I apologize this has run on for a while, and I thank anyone who has read this far.  I am not a philosopher, and so I am sure that I haven't been 100% on-target with my statements above--please feel free to point out if I am in error.

The author of the article argues that there is no right to health care because he believes that there is no right to health care.  He doesn't back up his claim in any meaningful way, and chooses to attack the *right* to health care by focusing on problems with the *delivery* of health care--two very different arguments.


If anyone who reads this would like to point out flaws in my argument or take a different position, please do.  I really do think that engaged, intelligent, civil discussion is an important part of our democratic process.  Please comment!