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.

Urgent Care Reflection

By Anna Holman

In Urgent Care, fall means the beginning of cold season, where patients with sore throats start to fill every other room. As a medical student, these visits are pretty straightforward, however, the challenge comes with the conversation surrounding treatment. Patients with cold symptoms don’t usually come into Urgent Care for Tylenol and nasal saline irrigation. Most people are already doing some version of symptomatic management before they come in. They often come in because they think they need antibiotics. In the cases where the symptoms seemed to be viral in nature and antibiotics were not indicated, I realized how important it is to validate the patient’s experience of their illness while explaining the treatment plan. Patients who were more insistent about antibiotics often had a history of a similar illness for which they received antibiotics and found improvement.

One patient I saw had a long history of sinus infections, multiple sinus surgeries, and the chronic sensation of sinus congestion. She pleaded for us to give her antibiotics, telling us that she only feels like she can breathe normally when she is on antibiotics. She had just finished a 10 day course of antibiotics and wanted another 2 weeks to take until she had another surgery. Without a relationship or knowing the patient’s history, the visit was more challenging than a visit as a primary care provider might be. We tried to explain why chronic antibiotics could be harmful and not likely to improve her symptoms. I am not sure the patient was very satisfied as she left the clinic without antibiotics in hand, however I won’t ever really know how much our conversation sunk in with her.

Working in Urgent Care reminded me of how much I like to have follow-up and to develop relationships with patients. As a medical student with short rotations, it is fairly uncommon to see a patient over a long period of time, but even just seeing a patient twice in a rotation felt gratifying to me.  In my Urgent Care rotation, I would suture a laceration, but hardly ever got to see how the laceration healed. In this way, it was harder to learn from mistakes and I was left just hoping that my knots held and the scarring was minimal.

The Urgent Care setting is a good middle ground for patients. It is less intense than the Emergency Department and I found that many patients preferred the Urgent Care to the Emergency Department. For this reason, it was crucial to quickly identify which patient conditions were beyond the scope of the Urgent Care setting. This was never a black and white decision. People often tell me “Patients don’t read the textbook” and I found this to be especially true in this setting. Chest pain and abdominal pain in the Emergency Department is fairly straightforward because of protocols and the availability of advanced labs and imaging. Chest pain and abdominal pain in the Urgent Care setting involves a little more subjective sensing of a patient’s condition and an emphasis on the physical exam for objective findings. In the end, it was often a judgment call and “better safe than sorry” principals that won over conservative management. I never regretted sending a patient to the Emergency Department, but again, I still wished for the follow-up visit to see how everything turned out.

Urgent care is a unique area of health care, a setting I had never considered when choosing to pursue a career in family medicine. I saw a wide variety of medicine and again saw how important it is to develop good rapport with patients, no matter how short the relationship may be. The basic principles of good history taking and a focused yet complete physical exam were key to management, but so was having a subjective sense of patient acuity.

Anna Holman

Anna Jackson Holman is a fourth year Medical Student at the University of Utah going into Family Medicine.

After Match Day

view from rock

By Anna Stomberg, MD

Every year the month of march brings a flurry of excitement. For some March means a time to anxiously await the arrival of the first green sprigs of grass marking the beginning of spring, others – to fill out their lucky march madness brackets and accurately predict the years NCAA champion, and to a small, but ever so influential population of brilliant medical students it means finding out where they will train and begin to develop their career as a physician: THE MATCH.

I still remember the day of the match like it happened yesterday. I barely slept the night before finding out my fate and attempted to play off the morning like it was just an ordinary day. I walked through different scenarios and tried to play out how I could react to least subject myself to social scrutiny. Pondering things like “What if I don’t end up where I want,” or “What if I cry?” The uncertainty of my emotional state was terrifying.

Flashing forward to the actual ceremony, I held the envelope in my hand as I thought back to my rank list of locations across the United States….I was likely in for a big change from my comforts of residing in Minnesota my entire life. A change I had made my rank list to reflect.

I anxiously tore through my envelope to reveal the words printed in black and white Times New Roman font: “University of Utah Affiliated Hospitals.” I was ecstatic and now began the quest of moving states a 24 hr u-haul drive across the country.

My intent of writing this blog post was not to walk you through my Match day two years ago, but to provide my top 7 suggestion on moving across the country and what do After the Match and starting the busiest, but most rewarding part of your medical training.

1.) Suggestion number one – Find a place to live and put time into researching! When you’re not at the hospital, you are at home. It should be a place to relax and kick back. Seek out good neighborhoods to look for housing and if you can afford to fly to the city to look at housing it is totally worth it. Evaluate proximity to work, parks, recreation. I got a flight to Salt Lake City for around 100 dollars flying on a Tuesday and back home on a Wednesday. The two cheapest days of the week to fly.

2.) Suggestion number two – Move to your new city AT LEAST two weeks early. I believe this is essential to get all of your belongings settled before residency starts and to do something FUN to explore your new surroundings! I moved to Salt lake City and then spent a rejuvenating week in Moab and then Zion before the grind of the residency
routine began.

3.) Suggestion number three – Make a plan for how you will stay connected with others, skype, facetime, phone calls. Being away from home and friends is difficult and you’ll need them even when they are far away.

4.) Suggestion number 4 – Find a doctor and dentist for yourself. Even though we are in the medical field we are sometimes the worst patients. Take care of yourself and establish yourself with a physician that can be there for you when you need them.

5.) Suggestion number 5 – Make a routine outside of medicine and SCHEDULE it. Your life is at the hospital. Take time to make friends and acquaintances outside of the hospital and take a yoga class, go climbing, to the dog park, skiing, biking…the possibilities are endless.

6.) Suggestion number 6 – Get a financial advisor, and make a budget. But seriously… If you are like me you have spent a lot of time buried in books, but none of them involved vocabulary like “investments,” “retirement,” “disability insurance,” “Roth IRA’s” or “TAXES.” It’s not like we’ve made money in the past 4 years or anything… I was however real familiar with the terms “debt” and “interest” which emphasizes the need for a financial advisor. A tidbit of advice is that many firms offer pro-bono work for residents in hopes of gaining clients for the future – seize the opportunity.

7.) Suggestion number 7 – Look at your weeks of vacation during residency and GET OUT OF TOWN. Adventure out of your bubble to explore your new state outside of the medical circle. There are unique places everywhere. Utilize your new place in residency to explore a new locale.

And Lastly: HAVE FUN. Residency is a great time to develop relationships with people all over the world, from different backgrounds, and different training that we can all learn from. Never forget your roots, but don’t forget to seize the opportunity to learn something new!

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Anna Stomberg, MD is a second year Family Medicine Resident in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.