Wednesday April 16, 2014





Reid: Patient-centred care sets out goals

In the last decade there has been a lot of reference to a novel approach to health care called “patient-centred care.” I didn’t understand what was new about this — it seemed to me that the patient had been the focus of everything since the first few days of medical school.

The concept became much clearer after reading a series of articles in the March 1, 2012 New England Journal of Medicine.

It is true that medicine has been more “disease centred” and “doctor centred” than anything. The doctor listens to the symptoms, does investigations, and then decides what needs to be done.

For example, Jim, 65, has diabetes and his blood sugar has been controlled with diet, exercise, and oral medication. Every three months his blood is checked for long-term sugar levels and every six months his urine is checked for micro-protein to see if there is any early kidney damage. His mildly elevated blood pressure and cholesterol have been treated.

A diabetes quality-of-care assessor appropriately gives Jim’s physician full marks and the quality assurance program, if there is one, rewards the doctor’s diligent care with a small bonus.

The only problem is that when you ask Jim what troubles him the most, it is the pain in his left hip on walking. While the diabetes still needs management, in the patient-centred care model, the primary focus switches to the hip pain.

The doctor’s role is to order the appropriate tests to ensure that the problem is osteoarthritis and not something more sinister. The doctor then explains the condition to Jim and provides him with ample teaching aids to understand the management options.

Jim’s responsibility is to confer to his physician what his goal is. Jim says the most important outcome to him is to be able to play golf with no more than minor discomfort.

Jim and his doctor discuss the situation together. Regular ibuprofen would probably help but could adversely affect Jim’s blood pressure and kidneys. They decide on regular coated aspirin and using a golf cart. If the pain worsens, hip replacement will be considered.

The goal may change with time. Ten years later, the pain is worse but Jim can no longer play golf anyway after suffering a small stroke. The goal now is to allow him to get around the house and yard. He and his doctor decide to try a walker, some home aids, and even regular ibuprofen (but not hip surgery) as at this point the goal is more about pain relief and less about strict blood pressure control or the risk of mild kidney damage.

The process then is much more individual. Pay for performance will be based on achieving the goals established by Jim and his doctor and not primarily on how well the practice guidelines for treating diabetes have been followed.

This is meant to be an equal partnership between Jim and his physician. “Patient centred” to me implies that the relationship has changed from “doctor driven “ all the way over to “patient driven.” Some patients might interpret this as tacit permission to have whatever tests, referrals, or treatments they desire without regard to necessity or cost.

Indeed, this was not the intention and perhaps “goal-centred care” would better reflect the philosophy of this new approach to care.

A discussion of the goals and then the management options will take some serious time. The physician cannot just list the options and expect the patient to make all the decisions; after all the patient didn’t go to medical school. The doctor must educate and provide guidance in a way that decisions are jointly made.

The ideal partnership will generate mutual trust so that the patient will be comfortable with the options, risks, and benefits provided by the doctor.

The doctor may need to advise whether a particular patient goal is appropriate. Shirley has had a severe stroke and has almost no use of her left side. Her goal is to live at home but in the absence of any relatives who can live with her, this may not be possible and she may need to alter her goal to finding the type of assisted living best suited to her.

As one article in the NEJM series summarizes it, this approach is all about “what matters to you” not “what’s the matter with you.”

Dr. Russ Reid is a retired Kamloops physician.





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