“I’d like an MRI for my leg pain. I haven’t had an MRI for many years, and I’m worried.”
These were some of the first words I heard from a patient I was seeing for a new patient visit. Based on this patient’s story and physical exam, her pain was most consistent with a muscle strain. My preferred approach to manage this complaint was to ask the patient to rest her leg and see physical therapy.
However, my patient felt very strongly that she wanted imaging to verify there was nothing amiss. After some discussion, we decided to get an x-ray that ultimately showed no abnormalities.
I am sure any health care provider has a similar story — a time when a patient’s desires led to provision of often wasteful, non-evidence based, and at times harmful tests or treatment.
There are many reasons health care providers often provide care requested by patients that may conflict with their clinical preferences.
One is that in the United States health care system, significant value is placed on both patient autonomy and shared decision making. We want to ensure that patients have a say in their own medical care.
However, I fear these values have produced a health care system where strong-willed patients are able to dictate the care they receive, often resulting in delivery of non-evidence-based care.
Take the example of antibiotics for sinusitis. Studies have repeatedly shown that for uncomplicated acute sinusitis, antibiotics should not be prescribed unless the patient has a prolonged course. In fact, this is among 15 Choosing Wisely recommendations from the American Academy of Family Physicians. Nonetheless, a 2012 study showed rates of antibiotic prescription were approximately 80 percent.
We don’t know for sure why antibiotic prescription rates remain so high, but one factor is certainly patients’ expectations that antibiotics will be provided. As a third-year medical student, I remember several patients during my ambulatory medicine rotation that expressed dismay when the clinic preceptor chose not to prescribe any antibiotics after only 2 to 3 days of symptoms.
Another reason health care providers acquiesce to patients’ requests for diagnostic tests or treatment measures is simply that we want our patients to be satisfied. We value the physician-patient relationship and don’t want to jeopardize it.
I know part of the reason I ordered the x-ray was to help in establishing rapport with my new patient. While it was highly unlikely that the x-ray would add any meaningful data, it might help my patient feel heard and reassured.
With the passage of the Patient Protection and Affordable Care Act, patient-centered care became a central part of quality care. Most importantly, it not only paid lip service to patient-centered care but also provided some bite by tying reimbursements for Medicare and Medicaid patients to patient-related outcomes.
In particular, nearly one-third of payments for hospital services are tied to the patient experience, as measured on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. As a result, there is a significant amount of money on the table tied to patients’ perceptions of their health care.
While patient-centered care is a broad idea, I feel that as health care providers, when we hear patient-centered care we interpret it simply as patient satisfaction. Given the value, we place on shared-decision making and the new financial incentive for patient satisfaction, I worry that we increasingly find ourselves in a position where we feel inclined to provide patient-dictated care.
As trainees at the beginning of our careers, I am especially concerned that my fellow residents and I are particularly at-risk of providing this type of care. We are training at a time when there is an unprecedented focus on the patient experience. With our time constraints, it is easy to provide patient-dictated care and simply call it patient-centered care.
But is this really the kind of care that we want to provide? No, of course not.
Patient-centered care is not only about patient satisfaction. As noted in a 2012 JAMA viewpoint article, patient satisfaction is a necessary part of patient-centered care, but they are not one and the same. While there is no definitive definition of patient-centered care, several articles detail the many aspects beyond patient satisfaction that should be included in patient-centered care.
We no doubt value patient’s autonomy and patient satisfaction but after years of training, we do bring some insight to the shared-decision making process. And it would benefit our patients if we remember that. Truly patient-centered care requires our clinical decision-making to ensure not only patient satisfaction but also good patient outcomes. We must strive for patient-centered care, not patient-dictated care.
Elaine Khoong is an internal medicine resident. This article