21 July 2017

Arguing at cross-purposes

Clinical Patients

“When I use a word,” Humpty Dumpty said, in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.” 

“The question is,” said Alice, “whether you can make words mean so many different things.”

Yes, Alice, we can and we do.

The ambiguity of commonly used words or phrases often results in misunderstanding.

Consider this recent exchange. “You can’t call that patient centred”, “yes I can”; “no you can’t”; “yes I can”. The protagonists gave up, agreeing to differ, but without understanding that patient centred is ambiguous.

Let us unravel this.

The patient-centred clinical method

“T he patient-centred clinical method” was a concept that emerged in the early 1980s in Canada. Ian McWhinney and his team at the Department of Family Medicine, University of Western Ontario sought to expand on the then prevailing doctor-centred clinical method.1

Doctor-centred medicine utilises biological science to understand, diagnose and treat disease. In pursuit of clarity, let us call this the biological model of care.

The patient-centred clinical method embraces the biological model while expanding it. It extends the horizon by emphasising the need to understand and manage the patient’s experience of illness – sometimes called the patients experience of dis-ease.  Diseases are more or less identical, while the experience of illness, or dis-ease, is unique to each patient.

The patient-centred clinical method has the following components:

• Exploring both the disease and the illness experience

• Understanding the whole person

• Finding common ground with patient

• Incorporating prevention and health promotion

• Enhancing the patient-doctor relationship

• Being realistic

It moves away from “doctor knows best” to “learning what is best for the patient with the patient.” Since the 1980s, research continues to demonstrate the effectiveness of the new method; it does improve health outcomes. The evidence supports the total package but points to gaining common ground with the patient as the crucial component.

The team at Western Ontario argues that there is a compelling moral case for the new method independent of the evidence that it improves patient outcomes.

GP educators in Australia have long embraced the patient-centred clinical method. When you hear GPs and colleagues from the wider medical community describing the satisfaction they find in their work. they are usually describing the benefits of working in the new patient-centred paradigm.

Here is a description of work in palliative care that captures the essence of the paradigm. “Our work elicits and honours patients preferences/desires, it is really about closing gaps between their hopes and the outcomes that are medically achievable. This bridging work facilitates the co-creation of shared goals and realistic, actionable plans that get patients closest to (their) desired outcomes while protecting them from interventions that will not help”.2 This is patient-centred medicine at its best, and it is a nice description of finding common ground. GPs will recognise it as a celebration and description of much of their own work.

Professor Dimity Pond captures this aspect of general practice in the following message. She writes: “I have been marking medical student case reports from general practice all day today. They report on a huge range of complex problems dealt with by GPs. Impossible problems, many of them (we ask for difficult ones). Where the GP has to balance risks and benefits, costs and their patient’s total lack of money, ethical issues and psychosocial issues and drug interactions and complex co-morbidity. And we do it! Every day! And the students report that it is done with grace and careful thought and not without cost to the GP themselves, and that they see the huge value of the longitudinal relationship with the patient and the family, and the GPs understanding of the community and all its subgroups.”

For the purpose of this article let us call this the patient-centred model of care rather than the patient-centred method.

GUEST ED PIC ALICE p182

The patient-centred medical home

This is one sense of patient centred, but there is another that is intended when it is used in the patient-centred medical home.

Confusion arises here because the meaning of “home” is not clear. It conjures up “house” and that is misleading. The intended meaning is clearer if we replace “home” with “health system”. The patient-centred health system is a system which enables both the biological and the patient-centred models of care to work efficiently in the production of desirable health outcomes.

Consider these two questions:

• Did the doctor understand why you came today?

• Were your health needs met today?

The first question is asking if the patient-experienced care as intended by the patent-centred clinical model? This is an aspect of patient experience on which the patient can reliably report. They know if they landed on common ground with their doctor today.

The second question is one that an Australian can’t answer. Nor can their doctor! (There are exceptions). The information needed to answer this question is either not available, or it is locked away in regions of the electronic medical record that take time and effort to access.

The question is asking if the patient’s treatment is optimal. It is asking if the patient has received all of the preventive intervention as recommended by the Red Book.

Related questions include:

• Should one of your medications have been de-prescribed today?

• Can you access a dashboard that describes the progress you are making towards your health goals?

• Has your care plan been amended to include the recommendations of each of your specialists? Recommendations contained in perhaps scores of letters scanned into the doctor’s computer.

These questions are asking about another kind of patient centeredness. It goes beyond asking how patients feel. It asks if their care is as appropriate as the evidence suggests it should be. It asks if their care is helping them achieves their health goals.

The patient-centred health system unblocks the bottleneck created when the doctor has to do everything.3 When the doctor has to do everything, it is inevitable that not everything that ought be done gets done.

This system surrounds the patient with a supportive team. This liberates the doctor to do what only the doctor can do. Similarly, nurses do only what nurses can do, and so on it goes for each member of the team.

It is possible for quite complex teamwork to develop in the Australian health system, fragmented as it is. So, for example, the Western Sydney primary health network commissions a clinical pharmacist to visit participating practices on a regular basis. The pharmacist is part of the team and has access to patients, doctors and the health record. This has resulted in measurable improvements in both quality of care and professional satisfaction of all the team.

High quality IT will not by itself produce efficient teams. Yet teams cannot function efficiently without high quality IT. In the best health systems the time and effort required to get data in and information out of the computer is minimal. Alarmingly it seems that the current ambition of My Health Record is to provide reams of shared data, when what is required is information shared in real time at every point of care.

“At every point of care” is a reminder that patient-centred health system reform is not simply a reform of general practice, but a reform of the health system and of general practice within it.

“The question is,” said Alice, “whether you can make words mean so many different things.” 

The answer is we can, and we do. “Patient centred” has at least two meanings. The marvel is that so much good patient-centred care (in the first sense) is delivered in a health system that is not patient centred (in the second sense).

References:

1. Stewart M. et al Patient-Centered Medicine, Transforming the Clinical Method. 1995 Sage Publications California

2. Kirkland KB. Finding Joy in Practice, Cocreation in Palliative Care. JAMA 2017; 117 (20): 2065-6

3. This is an issue with which Moira Stewart and colleagues wrestled in 1995 (ibid page 102.) “… we examine the issue of being realistic in terms of what a single practitioner can reasonably be expected to achieve in providing patient centred care, given normal human limitations.” It is an issue that Dr Kirsten Meisinger (Medical Staff President, Cambridge Health Alliance and Visiting Consultant, Went West) argues is resolved by the PCMH.

Dr Michael Fasher is Adjunct Associate Professor at University of Sydney and Conjoint Associate Professor at Western Sydney University