The New England Journal of Medicine published an article a couple of years ago entitled Defining “Patient Centered Medicine”. It began with a light touch of reality:
A patient consults an orthopedist because of knee pain. The surgeon determines that no operation is indicated and refers her to a rheumatologist, who finds no systemic inflammatory disease and refers her to a physiatrist, who sends her to a physical therapist, who administers the actual treatment. Each clinician has executed his or her craft with impeccable authority and skill, but the patient has become a shuttlecock. Probably a hassled, frustrated, and maybe bankrupt shuttlecock.
Before we are all done with this earth we will all have had such experiences.
In case it escaped your notice, a shuttlecock is that feathered projectile that is the center of attention in badminton. How does it feel to be a central part of the game?
As a patient advocate I consider myself a realist and I realize we have little leverage in the game. Oh yes it is our funds that pay doctors, hospitals and labs; however these funds are managed by well shielded agents whether they be the trustees of the social security system, Congress, or the trustees of insurance companies acting as agents for our employers.
As days go by our leverage is less. I grew up in an era where my life was in the hands of a neighborhood family doctor. My mom had maximum leverage in accessing my care. One call to Dr Mahoney and I was on my bike to see him if I could drive. One call from him and I stopped at the local pharmacy on the way home for my meds, on the rare occasion he did not give them to me for free. And if those meds didn’t work, one call to a handful of Dr Mahoney’s friends and I had a specialty visit that day. The business of medicine was once neighborhood and community based.
Not so today; it is big business. And making it patient centered is lot like trying to make Microsoft’s Support network consumer friendly.
Fortunately, hospitals are still community based, because like firehouses time is of the essence; but they are more isolated than they once were. Once and long ago they were owned by physicians, now the physicians are owned and employed by hospitals. They are large and complex businesses. They compete in market that is far from free and hospitals are the prey of contemporary politics. If they have no community conscience they may thrive; if they have a community conscience they struggle. They have a capital structure that caters to admissions, emergencies and beds. They are under mandate to reduce admission and stays in the days of growing chronicity of an aging population. How can they not be self-centered. Where then is the room for patient centered focus, when statistically they are being asked to be less patient centered. Is there any national policy and guidance for this transformation and last but not least what are the opportunities that lie within this transformation?