Patient Centered vs. Patient Dictated Care

This article was originally published at Physicians Practice.

Kyle Bradford Jones, MD

Patient-centered care (PCC) seems to be a popular buzzword among policymakers and administrators in recent years. Indeed, many physicians see our health care system as payer-centric, many patients see it as physician-centric, and no one seems to see it as patient-centric. While putting the patient at the center of what we do as physicians is critical to improving the triple aim of better care, better health, and lower costs, it is important to keep in mind what this exactly means; PCC is not the same as patient-dictated care (PDC).

We have all experienced patients who demand certain tests or treatments and see the physician’s role as merely rubber-stamping whatever is desired. This is a common trait among millennials, but also older generations who now have access to all sorts of information, both correct and incorrect, through the internet. Oftentimes these requests are accurate and warranted, but oftentimes they go against medical evidence or our clinical judgment as physicians. The example often given is of a patient with a viral upper respiratory infection who demands antibiotics. Many physicians fear negative patient satisfaction scores or losing a patient in a competitive market, and so will prescribe the antibiotics as the patient requests. This has obviously negative ramifications for antibiotic resistance and poor care, but these are the incentives that have been set for us by many payers and administrators. It is only human nature to follow the incentives.

PDC does not have to be something that compromises our practice. PCC does not mean that full decision making autonomy is given to the patient, just as routine care does not demand that the physician provide full decision making. It has been shown that many patients who demand certain care, such as antibiotics when not warranted, do respond to proper communication and explanations of why it is not merited. An acknowledgement of their desires is critical, but an informed discussion of why the request is not appropriate should occur. This is actually the definition of PCC—allowing the patient to make an informed decision together with the physician. A respectful, trusting relationship obviously improves this discussion and the patients willingness to listen to medical evidence and expertise, but even more acute settings where a relationship has not been established can be successful in these aspects.

The problem inherent in this advice is that physician’s schedules and time with patients is being squeezed. How can we expect PCC, patient satisfaction, quality of care, or even physician satisfaction, when the system has been moving towards less face time with patients and more administrative duties for so long? It’s quicker to write a prescription than to take time to explain to a patient why the prescription isn’t necessary. Many of us feel that we are being set up for failure by payers and administrators by being incentivized to increase RVU production, improve quality, and provide PCC when those two things are often contradictory. The trusting relationship with patients is being undercut by competing demands, lessening the likelihood of satisfying the patient. This then contributes to a payer-centric and perceived physician-centric way of caring for patients. Hence, such dissatisfaction among physicians, many of whom desire to leave the profession. If true PCC is able to be accomplished, this can actually improve the quality of care and decrease the cost of unnecessary and potentially harmful testing and treatments. Hopefully, proposed payments that incentivize team-based care and move away from fee-for-service will provide the ability to spend more time educating patients, both by the physician and by ancillary team members.

While physicians are not merely around to sign off on anything a patient wants, the discussion, trust, and education of patients moves the perception of care from patient-dictated to patient-centered. That may mean losing some patients who absolutely demand having what they want, but it will also strengthen the binds with many patients in your practice. After all, that is the reason so many of us entered medicine in the first place.

Kyle_Jones

Kyle Bradford Jones, MD is an Assistant Professor in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

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