موضوع حلو what patient centered care really means
What is “patient-centered care?”
Patient-centered care seems, at least from the wording of the term, like an unequivocal good, like mom and apple pie, but is it? Let’s start with the good. In his Health Affairs article from a year ago, Dr. Berwick attacked some aspects of the health care system that richly deserve attacking, specifically the inflexibility of so much of it:
Three years ago, a close friend began having chest pains. She headed for a cardiac catheterization, and, frightened, she asked me to go with her. As I stood next to her gurney in the pre-procedure room, she said, “I would feel so much better if you were with me in the cath lab.” I agreed immediately to go with her.
The nurse didn’t agree. “Do you want to be there as a friend or as a doctor?” she asked.
“I guess both,” I replied. “I am both.”
“It’s not possible. We have a policy against that,” she said.
The young procedural cardiologist appeared shortly afterward. “I understand you want to have your friend in the procedure room,” she said. “Why?”
“Because I’d feel so much more comfortable, and, later on, he can explain things to me if I have questions,” said my friend.
“I’m sorry,” said the cardiologist, “I am just not comfortable with that. We don’t do that here. It doesn’t work.”
“Have you ever tried it?” I asked.
“No,” she said.
“Then how do you know it doesn’t work?” I asked.
“It’s just not possible,” she answered. “I am sorry if that upsets you.”
Moments later, my friend was wheeled away, shaking in fear and sobbing.
What’s wrong with that picture?
Most doctors and nurses, I fear, would answer that what is wrong with that picture is the unreasonableness of my friend’s demand and mine, our expecting special treatment, our failure to understand standard procedures and wise restrictions, and our unwillingness to defer to the judgment of skilled professionals.
I disagree. I find a lot wrong with that picture, but none of it is related to unreasonable expectations, special pleading, or disrespect of professionals. What is wrong is that the system exerted its power over reason, respect, and even logic in order to serve its own needs, not the patient’s. What is wrong was the exercise of a form of violence and tolerance for untruth, and–worse for a profession dedicated to healing–needless harm.
To the extent that hospital policies are rigid, inflexible, and not necessarily in the patient’s best interest, Dr. Berwick remains on firm ground. In counterpoint, I will admit that I’ve had the occasional request by a family member to be in the operating room when I’m working and personally I don’t in general think it’s a good idea to allow friends and family in the operating room. I do, however, think it would be acceptable for everyone, as is done with pediatrics, to allow a family member or friend into the O.R. until the patient has gone to sleep. Be that as it may, I don’t disagree at all that many hospitals have policies and procedures that are not patient-friendly, much less patient-centered. Indeed, I’ve at times referred to such policies as “patient-hostile” and encountered them when visiting family members in the hospital. Coming from that perspective, I can say unequivocaly that Dr. Berwick was perfectly correct to castigate such policies. He even described three maxims of patient-centered care that are indeed quite admirable:
“The needs of the patient come first.”
“Nothing about me without me.”
“Every patient is the only patient.”
The first maxim is self-explanatory. The second refers to the need to collaborate with the patient, not to make decisions without informing the patient and discussing them with him. The third is more or less a restatement of the first, at least in my book. Dr. Berwick, however, takes it farther:
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.
While this sounds on the surface quite reasonable, as in many things the devil is in the details, more specifically in the interpretation of what these things mean. There is no doubt that the age of the paternalistic, “doctor knows best” model of health care is gone. For the most part, this is a good thing, although at times I’ve discovered that there are actually quite a few patients who actually want their doctors to tell them what to do. They become uncomfortable, sometimes even angry, when I present options to them, discuss the pros and cons of each option, and in essence leave the choice to them with my advice as to which option I consider the best. Indeed, early in my career, I actually got feedback from my division chief that I was perceived as being too wishy-washy and indecisive by some patients, as though presenting options suggested indecision. Maybe back then I just wasn’t that good at doing it yet, and I got better with time. At least, I hope so.
In any case, it’s a fine balance, and, I suspect, patients expect more decisiveness from surgeons, who are going to cut into their bodies, than from internists, who are not. Be that as it may, I fully accept that every doctor-patient relationship should represent a collaborative effort in which patient needs and wants need to be taken into account and, wherever it doesn’t conflict with science- and evidence-based medicine, patients’s wishes should be paramount.
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