Real Healthcare Reform
Although political discussion of healthcare reform in the United States today tends toward buzzwords and scare tactics, profound changes to healthcare delivery are currently underway. At the Quality Colloquium, which I’m attending this week, providers, executives, consultants, and consumers/patients are talking about transformative changes in the way care is delivered and in the definition of “healthcare” itself.
Various terms get at different elements of this transformation: patient-centered care, patient engagement and empowerment, shared decision-making, informed consent. It’s clear that the role of the patient is changing and, therefore, the role of the provider, too. Much of this conversation focuses on patients with chronic conditions, where the patient’s understanding of the disease, treatment options, and commitment to a care plan are acknowledged as more determinative of outcomes than a physician’s prescription. More than once today, I heard a speaker point out that a patient with a chronic condition who spends perhaps a few hours each year in a physician’s office spends more than 5,000 waking hours each year taking care of him- or herself, continually making health-related decisions. If the physician’s advice, information, and treatment don’t match the patient’s preferences, values, and socio-economic reality, what are the chances that patient will be “compliant” with the physician’s plan?
Coincidentally, just prior to diving into these discussions of patient engagement at the Colloquium, I listened to an archived edition of a WIHI program called “Minimally Disruptive Medicine,” which also focuses on the evolution of care and treatment for patients with chronic conditions. Victor Montori and Nilay Shah, both from Mayo Clinic in Minnesota, describe their work with shared decision-making and patient-centered medical practice.
Given the competing demands of myriad available treatments, including lifestyle choices and medications, and actions governed by clinical guidelines on which physician’s performance may be graded and reported, patients may find themselves with care plans that seem impossible to manage and fulfill. Is it time to re-evaluate some of these guidelines in the context of shared decision-making and patient-centered care? Are there times when a patient’s non-compliant behavior should be seen as civil disobedience? Has the patient been able to voice his or her preferences and goals for treatment? On the other hand, physicians may feel some screenings or treatments are non-negotiable. “Because I said so” is not likely to lead to better-informed decisions in the future, but is there enough time available for full discussion of the options?
This WIHI program is available for free on the IHI website or through iTunes. Montori and Shah share their work at a website and blog also called Minimally Disruptive Medicine.
Montori and Shah’s questions about standardized clinical guidelines and performance measures serve as a natural segue to another thought-provoking work currently receiving lots of well-deserved attention. In his most recent New Yorker article, “Big Med,” Dr. Atul Gawande observes that medicine seems to be emulating chain restaurants, such as The Cheesecake Factory, as it searches for ways to improve the quality, reliability, safety, and cost of healthcare. Although physicians are notoriously suspicious of anything that limits their autonomy—never mind being pressured to practice “cookbook” medicine—Gawande and many large hospital systems in the United States see advantages in standardizing the way care is delivered, especially now that value and quality are beginning to effect payment. Patients—Gawande’s mother among them—are beginning to see the benefits, too.
Fans of Gawande’s writing will enjoy his easy, masterful weaving together of research, anecdotes, and lessons learned: Gawande hanging out with the broiler-station cook in The Cheesecake Factory kitchen; hearing about the regional restaurant manager’s mother and the disjointed, ineffective, and humiliating inpatient experience she’d recently suffered at a local hospital; Gawande’s own mother’s very different experience with knee replacement as it has been standardized at Gawande’s own hospital; and the disruptive innovations taking place in a team-based “tele-ICU” run by Steward healthcare system.
At the end of this long and entertaining—yes, entertaining—read, Gawande concludes:
Patients won’t just look for the best specialist anymore; they’ll look for the best system. Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more. We’ll also have to figure out how to reward people for taking the time and expense to teach the next generations of clinicians. All this will be an enormous upheaval, but it’s long overdue, and many people recognize that. When I asked Christina Monti, the Steward tele-I.C.U. nurse, why she wanted to work in a remote facility tangling with staffers who mostly regarded her with indifference or hostility, she told me, “Because I wanted to be part of the change.”
These approaches to reform—(1) optimizing efficiency and effectiveness through standardizing treatment and (2) engaging with patients as full and unique partners in healthcare planning and implementation—don’t have to be at odds. If we get this right, we’ll standardize for maximum safety and efficiency while customizing the human, social and biological elements in ways that also lead to improved outcomes and satisfaction for all. We have a long way to go, but these recent experiences leave me feeling optimistic.