Healthcare Reform

Achieving patient-centered care is difficult, yet essential; paternalism is, of course, out.

The editorial, "Patient-Centered Care; What Is the Best Measuring Stick?" by Drs. Lin and Dudley (Archives of Internal Medicine), begins with an apropos quote of Sir William Osler: "The good physician treats the disease; the great physician treats the patient who has the disease."

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It continues by establishing a fundamental point of contention in the current health care debate: our care is fractionalized, oftentimes, uncoordinated and thereby compromised. Consequently, patients are inadequately involved in decision-making; at the very least, they may be uninformed. "Poor-quality decision making can lead to lower patient satisfaction with care, lower adherence to treatment plans, and worse quality of life. Substantial physician barriers to high-quality, patient-centered decision making include lack of time for detailed discussions during clinical encounters, lack of effective communication skills, and misalignment of financial incentives."

Grace A. Lin, MD, MAS; R. Adams Dudley, MD, MBA

Lin GA, Dudley RA. "Patient-Centered Care; What Is the Best Measuring Stick?" Arch Intern Med. 2009;169(17):1551-1553.

1. Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102(4):520-528.

2. Joos SK, Hickam DH, Gordon GH, Baker LH. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med. 1996;11(3):147-155. ISI | PUBMED

3. Holmes-Rovner M, Valade D, Orlowski C, Draus C, Nabozny-Valerio B, Keiser S. Implementing shared decision-making in routine practice: barriers and opportunities. Health Expect. 2000;3(3):182-191. FULL TEXT | PUBMED

The entire article is a good, brief and important read, but before ending this post, I want to emphasize one additional point made by the authors, which encapsulates the Osler quote, above—only focusing on the clinical outcome is too coarse a measurement. In one study, for example, a decision aid did not improve the outcomes as measured by adherence or HbA1c levels in type II diabetics; however, it did engage patients in making decisions about their medications.

I believe there was a large Hawthorne effect here, but more on that if you care to comment.

Mullan RJ, Montori VM, Shah ND; et al. The Diabetes Mellitus Medication Choice decision aid: a randomized trial. Arch Intern Med. 2009;169(17):1560-1568.

What is more important than the destination is the journey?