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Putting Patients In Charge Of Health Care, From the NY Times

A former boss once referred to health care providers' endless, inward-focused bureaucratic narcissism as "navel-gazing." Jack Welch framed it slightly more elegantly when he said something along the lines of "It's not that bureaucracies dislike customers. They don't. They just don't find them as interesting as they do themselves."

Now, Dr. Pauline Chen, writing in the New York Times, discusses Dr. Donald Berwick's philosophy of "patient centeredness" and its provocative implications that health care would work better if control was transferred from physicians to the patients themselves. According to Dr. Berwick, we face a system...
"...built...around clinicians that makes it impossible to customize care the way it needs to be. We don’t have a standard of services or processes that are comfortable for patients. We have built a technocratic castle, and when people come into it, they are intimidated.

"Patients keep having to repeat their name because the system has no memory. We dress them in silly-looking gowns. We give them the food we make instead of the food they want. We don’t let them look into their medical records unless they have permission. Health care keeps telling patients the rules instead of asking patients about their individual needs. What is said is, “This is how we do things here,” not “How would you like things done?”

"People get accustomed to this. They are trained to be passive, and passivity is not a good idea..."
I once had a physician Board member speak against a proposal to create an on-line portal through which patients could review their medical records. His argument? That patients, upon gaining direct access to their own clinical data, would "...just waste my time, barraging my office with stupid questions."

Even sadder, nobody on the board disagreed, not the administrators nor his physician colleagues, not the laypersons nor the business leaders. But Berwick's clarion call for a new way of thinking about health care may be turning a few heads and changing a few minds, perhaps even on THAT Board.

The new model is all about re-structured power relationships and financial incentives. I'm betting the latter is more amenable to fixing than the former.
"Some examples of this new model of care? Shared decision-making would be mandatory in all areas of care, with patient preference occasionally putting evidence-based care “in the back seat.” Patients and families would participate in the design of health care processes and services and would be a part of daily rounds. Medical records would belong not to clinicians but to patients, who would no longer have to get permission to look at them or call the doctor for lab results.

"Even the word “compliance” would become obsolete.

"As Dr. Berwick writes in his piece, '[We] would all be far better off if we professsionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives.'"
That sound you hear is not the gearbox on a '53 Studebaker. It's a few rusty paradigms being shifted.

Chen's interview with Berwick concludes with this:
"...the burden to change the system falls on the leaders, the stewards, the people who create the organizations where the workforce works. Doctors want to do their work in a patient-centered way; they really do. We have to fix the health care system so that it gives doctors the time to do the job they want to do."
Yes, health care needs to be fixed. Yes, compensation systems and incentives are a huge part of that "fixing." But I'm less confident than Berwick that physicians, universally, want to be more patient centered, especially when that implies giving up the power to tell "compliant" patients what to do because, well, "I'm the expert and you're not!"

The Takeaway: Many hospitals talk a good "patient-centered" game. You see a few systems adding "Chief Experience Officers" to their executive ranks or adopting a hotel-like "room service" approach to patient meals. Some offer less-revealing patient gowns. But it's all window-dressing (pun intended) until those power-based relationships change fundamentally and permanently.

Comments

Lynne said…
What other private industry/business/educational institution/etc. allows complete and total access to their customer records? When I worked for SBC/AT&T, NO customer had access to OUR records about THEIR business. Patients are customers, lest we forget. One of my favorite quotes is: Doctors are not servants of their patients, they are traders like everyone else in a free society and they should bear that title proudly considering the crucial importance of the services they offer.
Ayn Rand (1905 - 1982)

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