Patient-Centered and Doctor-Centered Care

These days it’s fashionable to say that if you give patients enough reliable information, they will become equal to doctors. What’s wrong, say these same people, is that doctors are overly authoratiative and have their own interests, not the patient’s interest, at heart.

In other words, what we need is more “patient-centered care.”To a certain extent, I agree with this. I agree patients should be given as much information as possible. I agree their options should be spelled out. I agree patients, informed through Internet search engines, are a good thing. I agree patients spending their own money and knowing what things costs, would save the system a lot of money.

The Institute of Medicine spelled out the essential ten elements of patient-centered care in 2001 in Crossing The Quality Chasm. These elements are,

1. Care is based on continuous healing relationships. This is the basic idea behind the medical home with primary care physicians offering continuous, comprehensive, coordinated care.

2. Care is customized according to patient needs and values. What the patient wants, not what the doctor wants, should reign supreme. Sounds good, but not always possible to fulfill.

3. The patient is the source of control, meaning the patient not the doctor should control care. This strikes me as a little naïve. Most patients want doctors to tell them the right thing to do, as I did recently, when as a patient, the doctor told me he was going to place a stent in my plugged coronary artery.

4. Knowledge is shared and information flows freely. Agree. Information should not remain stagnant in medical record.

5. Decision-making if evidence-based. This can become a little silly since much of medicine is an Art, based on experience and training, without retrospective “scientific evidence” of precisely what might happen.

6. Safety is a system property, meaning every hospital and every doctor’s office ought to have to check off a list of what might go wrong before making a decision, or “taking off”, like an airline pilot. This may be useful before major surgery or other dangerous clinical intervention, but it’s hard to apply when you’re seeing 30 patients a day.

7. Transparency is necessary. In short, medicine both in costs and consequences is often too “secretive.” I agree, but absolute transparency is seldom possible in most human exchanges.

8. Needs are anticipated. Agree. As much as possible, doctors should manage and satisfy patient expectations.

9. Waste is continually decreased. Of course. Cut to the heart of the matter, rather than assiduously document every detail and follow every rule or regulation.

10. Cooperation among clinicians is a priority. I would argue this already exists, although there are those who say “fragmentation,” i.e. specialization, is rampant.

What is being suggested here is a kind of 21 century clinical utopia with a personal generalist primary care physician overseeing the complete spectrum of care. There is a danger, though, of the perfect crowding out the good. Not all of us will be able to have the equivalence of a medical education, and not all of can be generals. Most of us need solitude, privacy, space, and, specialization for special needs. On the other hand, society needs less atomization and more anticipation of human needs. It’s striking the right balance that will make the difference.