Break the cycle of event centered care

Creating a patient-centered medical home within our existing system seems, at times, like a Herculean task. Getting all the pieces in place so that we can make the needed changes sometimes seems too vast to get it all right.

We find ourselves asking: Why bother? Is our healthcare system that broken? Is the way we take care of patients now failing, satisfactory, or outstanding? If we just continue on the path we are on, is there anything wrong with that?

Americans receive endless amounts of healthcare, but, we also have to ask, is it healthcare of endless value?

Fixing the American healthcare system requires first figuring out what the American healthcare system is, what is not working, and what we can do to make it better. At each step along the way we are faced with the even larger job of figuring out who all the stakeholders are and how to engage them effectively in this changing model.

We are a country with a long tradition of building a better healthcare system, creating a world where endless opportunities to heal and cure exist. And yet over and over we hear how our healthcare expenditures exceed that of every other country in the industrialized world, with poor outcomes to show for it.

How many studies do we need to demonstrate that so many of the interventions and extra “care” that our current system is purchasing are just not doing the job, not making Americans healthier? How many times do we need to learn that all we really need to do is rest, eat plenty of fruits and vegetables, avoid junk food, and drink lots of water?

The same advice our mothers gave us. And their mothers before them.

Our healthcare system is based on event-centered care. Each healthcare event is an interaction between a patient and some component of the system, either at their primary care provider’s office, in the emergency room, or at a specialist’s visit. A patient calls their doctor, cannot be seen when they want to be seen, gets seen by a covering provider. Symptoms are dealt with, and the patient is sent on their way.

Poor follow-up occurs when the patient leaves the sphere of the provider’s world, re-entering the community. We need to expand and extend care beyond the borders of these “events,” so that healthy behaviors and the pursuit of heath occur before, during, and after an office visit, an ER visit, a surgical encounter.

Imagine a patient at the end of an office visit with their primary care provider. They are cut loose, “discharged” back to the outside world, weighed down with new prescriptions, medical advice not clearly explained to them, consultations they need to set up, routine healthcare maintenance tasks they need to accomplish.

So often we discover when that patient returns that the prescription was not filled, the advice not heeded, the consultation made but never communicated back to the provider, and the age-appropriate screening put off yet again.

The next office visit is often spent cleaning up the “mess” from the last.

How can we break this cycle? Perhaps moving away from seeing the office visit as the only opportunity for health, and truly changing the focus over to the patient. Build a system that never stops caring for patients, even when they may be out of sight and out of mind.

Providers need to be given the tools, the time, and the resources to see the forest for the trees, to truly assess the health of each individual patient, as well as their entire panel of patients. Only then can a true healthcare team centered around our patients come to life.

Fred N. Pelzman is associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home

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  • buzzkillerjsmith

    Non-event centered care has its place, but I would submit that an emergency appendectomy has some value to the pt.

    Non-event centered care also requires a robust primary care sector. Good luck with all that.

  • Steven Reznick

    The outside the office visit education should occur in the home from loving well meaning adult parents. It used to be provided as well in the public schools in hygiene and home economics courses . Due to budgetary constraints and parental concerns about whether birth control and reproductive science are being taught ( and creationism is not) most school systems no longer have this. They used to teach simple and basic first aid as well.
    Funding for public and community health centers and education needs to increase. I proposed a mandatory national health corps taking each medical resident before they enter practice or specialty training and each graduate nurse and extending their education a year while they teach, work in schools, public health clinics, senior centers, adult living facilities, day care facilities and teach Americans how to eat healthy and take care of themselves to prevent illness. Policy wonks prefer to shorten residency training rather than lengthen it.

    • Guest

      The outside the office visit education should occur in the home from loving well meaning adult parents. It used to be provided as well in the public schools in hygiene and home economics courses.

      Bingo, bingo. On points one and two.

      My parents taught us most things having to do with healthy day-in day-out living, and modeled it as well. And we had both hygiene (I still remember the taste of the red disclosa-tabs we had to munch which would show us — and the entire class – whether or not we had been cleaning our teeth properly!) and home ec classes (cooking, shopping, basic nutrition, planning balanced meals, the lot) in school.

      Interesting that you should bring up birth control, “reproductive science” and creationism. We had none of those in my school (well, what “reproductive science” we had was actually taught in a real live science class, called Biology… we didn’t have classes on “safe fisting for teens”, “transgender awareness” or “abortion rights”). Anything even remotely touching on religion (i.e. creationism) was left to our parents — church was for Sundays, and very much in the private realm.

      And still somehow we managed to get by. Better, actually, than today’s kids, who are not taught home ec or hygiene but know how to get the morning after pill, how to “explore” their “sexuality” and how to put condoms on bananas.

      • LIS92

        I remember those days in home ec class. I also remember the girls that disappeared when they got knocked up. Perhaps their lives would have been difference if they had learned to put condoms on bananas.

  • southerndoc1

    “a system that never stops caring for patients, even when they may be out of sight and out of mind”
    Am I the only person who finds that a little scary?
    “Caring for” here means monitoring, measuring, manipulating . . .
    When a patient, I’m perfectly satisfied with event-centered care that I initiate.

    • Margalit Gur-Arie

      Read my mind… A gigantic lab full of human rats… and life as a cradle to grave medical experiment….

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