Should doctors be blamed for bad decisions by patients?

The Disease Management Care Blog attended a professional hockey game recently and it must say it was quite the spectacle.

While the athleticism on the ice was quite remarkable, the real wonderment involved the hometown fans. Questionable referee calls prompted thousands of all ages to chant phrases that the DMCB has not recently read in any medical journals, while the willingness of grown men to display, in stereo fashion, obscene gestures was only last witnessed by the DMCB during an early morning ER shift.

Given their apparent fondness for calorie dense foods and various carbonated beverages, it was also clear to to the DMCB that wellness, prevention and chronic illness management was not at the top of most the hockey fans’ agenda. Since there is a ready availability of high quality health care providers surrounding the hockey venue, the DMCB suspects most if not all of the gluttons on display were well aware of their downsides of their risky lifestyle.

So, is that their doctors’ fault?

While the DMCB was at the American Medical Association’s National Advocacy Conference, it was repeatedly reminded that the preferred physician answer is “hell no.” While the DMCB’s colleagues recognize the key to control of chronic illness is patient education, the sense of powerlessness over this issue was telling. Doctors talk, patients listen and, when the next visit rolls around, nothing has changed.

Enter “patient centeredness.” This has been defined by the Institute of Medicine’s Crossing the Quality Chasm report as any care that is “respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.” So, if a physician provides whole person care, comprehensive communication, coordination, support, empowerment and access on Friday afternoon and the patient washes three jumbo dogs and a plateful of nachos down with a pair of brewski’s that Saturday night, is that a breakdown in a physician-owned care process?

Common sense says no, but our systems for quality improvement have yet to catch up with this reality. Ultimately, says the DMCB, patients should be able to fully participate in shared decision making and decide for themselves whether an ideal body weight, an A1c less than 7% or taking extra blood pressure pills is worth it. Assuming they’ve been apprised of all the risks, benefits and alternatives, that should be their decision to make. Given their behavior at the hockey game, patients certainly enjoy making full use of their right to make bad decisions.

Which leads the DMCB to three recommendations:

1. In addition to measuring “process,” and “clinical,” “economic,” and “other” outcome measures, perhaps its time for the health care system to start learning how to measure “shared decision making” outcomes including counting the number of times patients at risk (the “denominator”) participated in a state-of-the-art risk reducing, engagement seeking educational session (the “numerator”). The DMCB has little doubt that when this is done right, variation will diminish and the quality curve will shift toward the better. Physician buy-in will also increase.

2. Physicians should be free to assume personal responsibility for the task of seeking patient engagement during all the free time they have (not) during their face-to-face patient encounters. A more reasonable alternative may be to outsource this, either to the other team members in a patient centered medical home or to companies (like this) that can scale this from one to thousands of patients.

3. Finally, hockey fans should recognize that persons unengaged in personal health improvement or risk reduction who also have no redeeming physical characteristics are not helped in their appearance by wearing a foam replica of an oversized hockey puck on their head.

Jaan Sidorov is an internal medicine physician who blogs at the Disease Management Care Blog.

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  • Muddy Waters

    If a patient decides to live an unhealthy lifestyle with high-risk behaviors (I.e. smoking) despite good counseling by a physician, then the consequences of that decision must be borne by the patient and not society. That is the problem with America today – nobody wants to accept responsibility. For example, if a smoker develops lung cancer and does not have private insurance or discretionary funds, they often get tens of thousands of dollars in medical care at society’s expense. That’s not right. If one has less resources available to them, then they should be even MORE responsible about their health.

    • carol

      So if I read you right the heck with those who are at the lower level of society, as they are the ones who usually do not have/cannot afford insurance. It is hard when you are just trying to keep your head above water to be able to afford a gym membership or have the time to take a nice walk, “During 1983–2002, adults with household incomes below the poverty level and those with less than some college education consistently had higher smoking prevalence(2). ”
      Those people often don’t have the money or time to take stop smoking programs, or afford wellbutrin, etc.
      It is not the doc’s fault, certainly, that their health may be worse than those who have insurance/money. Eating, smoking, etc choices are the individual’s responsibility. But as a society we have a mandate to help those who cannot help themselves.

  • Skeptical Scalpel

    Should doctors be blamed for bad decisions by patients? Why not? Doctors are blamed for almost everything else. And as Muddy Waters writes, it has to be someone’s (other than the patient’s) fault.

  • aek

    Not blamed for patient decisions – a resounding NO.

    However, what’s often missing between the prescription and the decision is a lack of the tools on the patient’s part to determine both HOW to achieve and maintain the behavior and ongoing coaching and counseling by the physician/designee. When people literally don’t have a clue about how to proceed, they likely will not own up to this as it’s embarrassing & humiliating or they don’t even know that they don’t know.

    That’s where I see the potential value in group appointments for managing chronic conditions. Putting six patients and their spouses together and intensively focusing on a key self management strategy allows for 90 minutes of customized teaching, peer support, hands on learning and pilot studies for efficacy and patient outcomes. Because they bring a support person, they can get built in buy in.

    Based on your post, where I’d start is with choosing nutrient dense whole foods, shopping the perimeter of grocers, basic food preparation/cooking (guest chef opportunity), food costs/budget.

    Then you can tackle eliminating added sugar, industrial seed oils, gluten and processed foods and the concomitant weight, appetite and taste re-regulation that will occur.

    That will transition into people feeling better (correction of dyslipidemia, metabolic syndrome, blood pressure, visceral fat) and having more energy, so next up is increasing activity. Etc.

    For us old fogeys, this is nothing more than elementary school health class. But it’s been lost and no one is picking it up, so best that it come from a trusted and reliable source.

  • Justin

    Behavior change is very hard even if you see a therapist 60 minutes, once a week. There is absolutely no way a PCP with 10 minutes and minimal training in behavior change therapy can exert any effect (if by chance s patient does change they were going to anyway). Any comments or hopes stating the contrary are pollyannish, put in the sky rhetoric of policy wonks who don’t work in the real world.

  • Steve Wilkins

    There is a fair body of published research which speaks to the lack of concordance between primary care physicians and patients on critical issues such as seriousness of one’s health condition, efficacy of prescribed treatments, etiology of medical conditions, health information sharing, etc., as well as the amount of physician “talk time” during routine office visits discussing these and other related issues.

    Factor in provider attitudes towards patients (such as those expressed by Dr. Sodrov’s impression of hockey fans) and you wonder how anything productive occurs during an office visit. Patient’s aren’t stupid – they can detect physician attitudes just as physicians can detect non-compliance.

    One consistent theme runs through just about all these studies – physicians tend to overestimate the time they spend talking with patients during visits about all kinds of issues issues. Of course there is not enough time during a 10 or 12 minute visit to accomplish everything but come on and no physicians are not reimbursed for providing services like patient education. But then what can physicians expect to accomplish when they spend less than 60 seconds on patient education or teaching a patient to take a new medication they didn’t what in the first place.

    The evidence suggests that there is plenty of potential “blame” which can be directed at the patient as well as the physician for why patient’s aren’t healthier. Rather than point fingers it would seem to make more sense to find solutions that work for both patients and docs…and no that does not require a wholesale rebuild of the US health care system. It simply requires docs and patients talking with one another in an open and respectful fashion over time. This ain’t rocket science!

  • Dr. Bill

    Steve: I detected no “attitude toward patient” in the article. I did detect a humorous discussion of a consistent problem with which I could identify. Modifying behavior often is more successful when humor is applied to keep the patient’s (and physician’s?) interest, as those of us that strive mightly to teach can often verify. p.s. I was the “Ring Doc” for a hockey game once (once was enough!) and a suture pack broke out after a player got all pucked-up!

  • ninguem

    The bar has to have somebody to sue.

  • Teresa

    Interesting discussion. I agree that non compliance is not the physicians fault. (By the bye, I am a nurse). However, I do believe there is a limited amount of time available for quality teaching. Patients do need to have a clear understanding of choices, ramifications of choices, and options/alternatives that take into consideration cultural mores, and socio-economic limiters. Unfortunately, nursing has little more time than physicians. With insurance mandates, DRG limitations, and a greater ethnic diversity in the patient population, the challenge seems greater than ever. Bottom line is that patients MUST buy in to their own healthcare concerns, and society as a whole shouldn’t be made to pay for those who don’t or won’t.