Donald Berwick is a physician at the forefront of the patient empowerment movement.
In a recent interview, he believes that medical care needs to be more patient-centered, in effect, “transfer[ring] control from doctors to the patients themselves,” and, “patient preference occasionally putting evidence-based care “in the back seat.”
I wonder how, as a pediatrician, he’s handling the anti-vaccine movement.
In response to a question on patient choices that come in conflict with evidence-based medicine, he says that, “Human beings have got to have the ability and the responsibility to make their own decisions. As long as they know everything they need to know, they should be able to make the decision. If we doctors feel a person is going to make unwise choices, we have to take on the responsibility of being teachers, educators and informers. We need to give people all the knowledge and information so they can make their decisions well.”
I’ve mentioned before that there are some that are unswayed by the medical establishment, especially in a polarizing issue like vaccines and autism.
If public safety is threatened, especially with the increasing number of parents refusing the vaccinate their children, does Dr. Berwick still believe they are making an informed decision?
Family physician Doug Farrago has doubts on Dr. Berwick’s vision, saying, “[he] believes patients are our peers. Really? Working together to solve a medical problem is not the same as being my professional peer.”
Indeed.
Related posts:
- Patient safety and the evidence
- My take: Patient tips, questioning tests
- Vaccines and autism: The last word
- When will doctors find it acceptable to deny medical services?
- A pediatrician takes the anti-vaccine movement head on
- Will comparative effectiveness research really save money?
- Screening for autism
{ 13 comments }
Patients are not peers. If they were peers they would have treated themselves. It is physician’s duty to steer the patient in the right direction. Otherwise the enormous amount of complexity that medical science has inherent, will confuse and paralyze the decision making of these patients. Telling patients their options is one thing, but it is our duty to make sure that we atleast try to tell them what the right choice is. Overcorrecting from Paternalistic Medicine to an extreme version of Patient-directed medicine can be devasting for the patients themselves. And that is harm to the patient.
This sounds a lot like the “child-centered” education movement, in which schools & teachers don’t instruct children but instead assist them in “exploring” whatever provokes their interest. While this can work well for the tiny minority of intelligent, self-motivating, broadly curious children, it’s a prescription for disaster when applied on a broad scale.
Similarly, “patient-centered” care that allows patient preference to trump evidence-based medicine will, in short order, render antibiotics useless as constant patient demand for them to treat viral infections turns all common bacteria into antibiotic-resistant strains.
Dear Doctor: I am not your professional peer. That’s why you: doctor me: patient.
Yes I need you to educate me and yes, I do make the final choice but really – I want you to tell me what to do. If I need surgery, tell me. If I need xx drug, tell me. I’ll take your advise. You’re the guy with the diploma(s) and the huge student loans.
NOTICE: This only works for me because I have a long, trusting relationship with my doctor. If he tells me something, I go with it. Many times I have been in his office and said “tell me what to do” and he’ll say “I think you should choose this” – and we know it’s best for me because he knows me, my needs, my risk tolerance, my fears… And a LOT of the time, I don’t like the thing that is best for me!
Empowerment can always be taken too far! Is there a way to encourage control via the one susceptible to harnessing the empowerment concept to control it by taking everything into consideration including evidence?
Regardless of the establishment, there will always be those that will hold fast and be difficult to un-sway from their ideologies on what they think is right and wrong.
In every aspect of life, public safety is threatened every day. One of those things that will never change, the question in the field of health is how do those in the field open the minds of those un-swayed to realization that their perhaps one sidedness decision is not that of an informed decision. Evidence must be utilized in part of the informed decision making.
I totally agree with you on the aspect a patient is not the same as your professional peer. I am a big proponent of those in the practice of medicine utilizing their peers more often to help come to a conclusion. There is always someone with a little more information or evidence on a particular item than we may hold ourselves. If a MD does utilize his or her peers to seek out answers for a patient or the patient’s family, there is a huge problem with that particular MD.
Patients and their families are not peers but need to be included in the treatment, after all it is the patients health that is being dealt with and not that of the MD whom the patient is dependent upon for answers.
Their remains to be in society on all levels those that remain unopened minded, hence the continued issue with not making properly informed decisions for the benefit of their or their children’s health.
Just saying everyone, everyone, needs to approach everything with an open mind. The evidence must be included, that is if there is evidence to include.
As a patient, I never want to be treated as a peer by my physicians. I want to be treated with respect and honesty, and I want to approach my treatment as a partnership between my doctor and myself. However, part of my responsibility for my own health is to listen to my doctors’ expert advice. While this may entail seeking an occasional second opinion, it will never extend to forming my OWN opinions unassisted.
The number of people, even among my own acquaintances, who do seem to believe this is a good idea is breathtaking.
Under P4P programs, I will suffer financially if my “empowered” patients reject evidence-based care. Will these patients accept the cost of their decisions and be required to pay more for health insurance?
Carol and Helen raise a valid point and it all concludes that both patients and physicians want the doctors to lead medical care. Patients come to the doctors to be guided onto the right path. They don’t come to the clinic to call their own shots.
A correction to a paragraph I wrote, I apologize for not catching it sooner. Last line to include the word NOT in my previous post of the paragraph below.
I totally agree with you on the aspect a patient is not the same as your professional peer. I am a big proponent of those in the practice of medicine utilizing their peers more often to help come to a conclusion. There is always someone with a little more information or evidence on a particular item than we may hold ourselves. If a MD does NOT utilize his or her peers to seek out answers for a patient or the patient’s family, there is a huge problem with that particular MD.
So will I be sued when the patient refuses treatment, then their lawyer argues later that the patient could not have “informed consent” because the MD is in the superior position? I have no doubts.
Kevin, it sounds just like that case you wrote about where the medicine resident didn’t order the PSA after having a long informed conversation with the patient. That was the definition of patient empowerment. And you see where it got all of them. Total joke.
What percentage of cases are such that there may be multiple possible actions that can be taken for the patient’s condition, where the available evidence does not clearly point to one of them being the best for the patient in that situation? Those would seem to be the types of cases where “patient empowerment” as discussed here may be most relevant. Of course, the doctor would have to inform the patient of the various options, including benefits and risks (and costs).
Sometimes I think Donald Berwick is the only reasonable doctor in the world–and the rest of you are status-obsessed goons. I think the word “peer” got everyone so upset–after all, doctors aren’t equal to their patients–and to suggest otherwise is absurd. The comments had nothing to do with Berwick’s actual proposal: ownership of records by patients and treating patients as human beings when they’re in hospital. What was I saying about status-obsessed goons.
Re peers: As a Ph.D. in stat, I am more than my doctor’s peer when discussing studies with a doctor. Indeed, I’m often appalled by the statistical ignorance of the average doctor. Other types of patients bring other types of expertise. Medical problems are simply not the exclusive domain of doctors.
Get real, docs. About 20% of your treatments do has any scientific validity. You make your money by manipulating fears of death and morbidity. You have bigger things to worry about than your “status.”
I’ve had doctors give me poor or outdated advice and not listen to me when I was telling them significant symptoms. I have had to live with the devastating results of that poor treatment.
I learned the hard way to read the entire PDR entry on every new drug I take and discuss it thoroughly with both the MD and the pharmacist. I scour the literature. I now take responsiblity to educate myself and seek out second and third opinions until I can discover a consensus.
To be fair, I have found some MDs who participate and support me in this process. I freely admit the limits of my abilities and I do depend on the experts. I just wish more MDs would do the same.
I’ve also been appalled at the poor design or inappropriate statistics in some of the medical research (I have a PhD). I find many MDs are too busy to keep up with the latest literature and are not interested when I bring it to them. And now we find how often the pharmaceutical companies control the research and research reporting so that the literature may well be significantly incomplete and biased.
Clearly we need better communication and a partnership between open MDs and educated patients to reach the best possible outcomes.
“Clearly we need better communication and a partnership between open MDs and educated patients to reach the best possible outcomes.”
Key words here are “educated patients”. This is a small but vocal minority. Most doctors love to have educated patients, but being confrontational and calling us “status-obsessed goons” does not help. I noticed how you found it important to mention your PhDd (both 11 and 12). Doctors don’t think they are perfect and know everything. We don’t claim to be statistical experts but make every effort to stay up-to-date (in fact we are required by law to attend CME) with relevant and well-supported research. Yes, we are aware that there are limitations and yes, we know that pharmaceutical-sponsoring is huge. Unfortunately, that is ALL we have sometimes.
I encourage my patients to read about their conditions and medications. Up-to-date has great patient handouts that I often print out for them. I think that most doctors welcome the “educated patient” but the line between “educated, empowered patient” and “arrogant, I-know-more-than-the idiot-doctor, entitled patient” is getting awfully blurry. Remember, the doctor also has exposure to many other patients and experiences that the patient doesn’t have. This goes a long, long, long way.
Finally, patient empowerment starts at home. It starts with taking care of yourself. It starts with diet, exercise, quitting smoking, etc. I am honestly sick of hearing the “I am the only one who cares about my own health. The doctors only care about keeping me sick” line from the obese smoker with COPD and uncontrolled diabetes snacking on Doritos and a regular coke in the room. I guarantee, I care more about that person’s health than they do. Is it paternalistic? Yes – it has to be. And the sad fact is that is the majority of the patients. I sincerely think that this is what is keeping the patient empowerment movement down.
My two cents – from someone who would gladly see an educated person concerned enough about their health to research it.
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