patient centered care

[Guest guest]

nice article. i was struck by the underlying operator at the apex of the pyramid, "i receive exactly the care i want and need exactly when and how i want and need it". as a matter of fact, i take issue with it. if the IMP chooses to deliver care to that standard, which i contend is unrealistic and unprofessional, if not impossible, it is also a setup for failure. it begs the question what are the limits of one's training and facilities? what are the limits of one's physical and emotional capabilities? where is the practice of evidence-based medicine? where are the professional standards by which we govern ourselves? if one provides services to a standard defined by the patient, one has effectively transferred control of one's practice to the patient. any business which does not clearly define what and how it performs it's

services, and leaves the definition of the services provided to the consumer, is quite frankly foolish, not only in terms of expectations and one's ability to meet them, but also from a risk management standpoint. "i wanted and expected you to provide this for me, and you didn't". those of us who are practicing a style of medicine which focusses on the kernel of health care, the doctor-patient relationship, must maintain appropriate boundaries, be clear about what we do and don't do, our limitations, and of course, our obligation to educate and discuss our patient's expectations, and whether they are reasonable. i am concerned that we not revert to the "superdoctor" who supposedly could do everything. we cannot right all the wrongs of the current health care system, and make up for those doctors who don't take the time with patients, to get to the bottom of

their worries and concerns. "i receive exactly the care i want and need exactly when and how i want and need it" is the basis of the boutique practice. i suppose if we lived in utopia, or if one were a multibillionaire, we might all have that. but would it still be appropriate? many of us complain that we don't get compensated for the time and effort in providing care management and telephone calls. many patients don't want to be seen, just be provided a prescription over the phone. now there's a patient expectation that fits right into "i receive exactly the care i want and need exactly when and how i want and need it". is that good medical practice? is that an appropriate standard of care? "i receive exactly the care i want and need exactly when and how i want and need it" will not solve this problem, only exacerbate it. even with "membership fees", it does not

resolve patient expectations, professional standards, nor address risk management. i depend on my history-taking and physical examination skills to determine what's medically appropriate and necessary for my patients, at a time when i can bring those skills to bear, within the context of my professional abilities and training, meeting professional standards. i agree that patients receive the care they need when they need it, however we must separate want from need. the IMP cannot be the be-all, do-all, however we can educate patients on the difference between the two. otherwise, want=need is a formula for disaster, which ultimately will not help us or our patients. we don't exist in a vacuum. we work in a health care system, which implies that there are a number of different entities which provide for patients-- ambulatory care, emergent/urgent care, hospitalization,

rehabilitation, and specialty consultation. to be sure, family doctors, internists, pediatricians and other generalists play a key role in helping patients navigate that maze. let us at the same time clearly define our role, our abilities and limitations, our professional standards, and our patient's expectations in a realistic fashion. some patients believe that they get to come into the office and tell me what to do, and have me sign off on what they want, merely because i have the medical license, and they are the patient. we can all agree how ridiculous that is. "i receive exactly the care i want and need exactly when and how i want and need it" is merely that in another form. we've already given up control of the practice of medicine to insurance companies. it is irresponsible to give up our professional responsibilities and standards to patients, or anyone else. certainly, to work collaboratively with patients, to improve access to care, to meet standards of preventive care, to intervene aggressively in chronic disease and to educate patients, are all critically important in guiding patients toward a path of good health rather than just maintaining a state of non-disease, or focussing on cure after the fact. we can all do a better job, and an ounce of prevention these days is worth far more than a pound of cure. we have better tools available, especially in the form of electronic relational databases, transfer of medical records and access to the internet, and evolving research and guidelines for the maintenance of good health. rather than define the doctor-patient relationship in a pyramid, with patient expectation at the top of the hierarchy, i would define it as a ven diagram, with overlapping areas of the doctor and patient, professional standards and

responsibility, evidence-based medicine, and patient expectation. i believe that's a more realistic approach to patient care. LL

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