The patient was a typical one in my primary care practice, and for those of you in my field, one familiar to you as well. Jim, as we will call him, was a middle-aged, obese male with a history of hypertension, hyperlipidemia, and diabetes, whose most concerning medical problem was his long history of noncompliance. He came in once a year for the physical his company required but otherwise ignored his health. This was his first physical with me, but I saw a decade of this same pattern in the EMR. In the last year alone, his previous PCP had tried contacting him 14 times with no response. Today, his A1c was 14%, and his blood pressure was 165/95.
As I read my predecessors’ notes—filled with statements like “discussed heart attack and stroke risk” and “needs help with diabetic diet but refuses referral”—I sighed deeply. Already, I could feel myself checking out for the visit, my shoulders tensing. Why care when obviously the patient didn’t?
Dealing with a noncompliant patient can be a struggle. What is the point of trying to help someone who does not want to be helped? In the same way, we write off a patient as a bad historian (though we, in fact, are the historians, and the patient is the primary source), it is easy to label the patient as the problem.
Western medicine loves to identify problems. Our system is built upon locating a problem, affixing an ICD code to it, solving it, and moving onto the next one. If the problem is not solvable, we throw medicine at it anyway or blame the patient. Never mind that the medicine we throw at one problem sometimes causes another. We add the new problem to the Problem List and let that dictate what tests and treatments we order and the care we provide. Problem-based thinking is everywhere. It is baked into the EMR, it is in our system of billing, and it is in our heads. How often do we think of patients as their disease, primarily describing them based on their illness?
But knowing you have a diabetic patient does not help you treat the person. Every patient with diabetes responds differently biochemically and psychosocially to the treatments we provide. People are not problems. Our medical system—having focused so long on problems—has forgotten that.
To combat the default problem-based approach, we need to change our mindset. Instead of focusing on problem-solving, what if we first try to clarify some shared goals to work on together? This framework switch is called goal-oriented health care. And it has the power to change the way medicine is done.
This was the grounding I gave myself before I walked into Jim’s room. Forget the A1c, forget the blood pressure, forget the neuropathy, forget the list of problems I had reviewed before stepping into the room. My goal was simply this: figure out what’s important to Jim and offer to help him with his needs.
It is not hard to get patients to discuss their goals and priorities, but not with direct questions. Let me demonstrate this point.
What are your health goals?
Think about it for a second.
What are your personal health goals?
If you are like the majority of the patients in my typical primary care office, you likely thought in infinitives: “To Lose Weight!” or “To Exercise More!” or “To Eat Healthier!” While these intentions can be good for our overall health, they are not really goals. They are strategies. Why is losing weight important? What might it allow the patient to do? In our medical culture, we obfuscate strategies with goals all the time. So, you can’t just ask a patient what their goals are directly. You will just get a list of strategies.
You do not need to ask the insurance company what they think our patients’ health goals should be; quality metrics are now a ubiquitous part of most of our lives, and most are strategies, not goals. According to our payers, these metrics magically translate into quality health care and so payers adjust reimbursement based on how individual doctors meet them. In some areas of the country, there are over 70 different metrics that different insurance companies want measured. It is insane! While I too want my patients to have an A1c below 7.5%, that measurement is not a goal—it is an objective, and it does not address the individual as more than their discrete problem.
A health goal is an outcome, one that doesn’t need to be qualified with a “so that” or an “in order to.” Goal-oriented care breaks down health goals into four categories: preventing premature death and disability, maximizing current quality of life, optimizing personal growth and development, and achieving a good death. By learning how to ask the right questions to help patients clarify these four goal types, we can subvert the current status quo where patients are distilled down to problem lists and make our care patient-focused.
I walked into the room. Before I could even introduce myself, Jim started, “I do not like doctors. I do not like coming to the doctor. I won’t take medicine, so please just sign my form so I can leave.”
“Oh, you can’t come to my office and not talk to me,” I fired back consistent with my usual probably-slightly-too-sarcastic demeanor, “But we don’t have to talk about diabetes or blood pressure. I just want to know more about you, so we can try to make you the happiest, healthiest you that we can.” I usually ask more questions about a patient’s day-to-day life before asking about specific goals, but today I realized I needed to get to the point quickly, “Is there anything you want to be able to do but can’t do because of your health?”
There was a beat before he began. Then it was a flood. He has one grandson that he wants to be able to run around with but struggles because of his knees. His deep love of fishing, but this pesky numbness in hands that is making it “d@$% near impossible to string a lure.” And don’t get him started back on his knees that stop him from going to his favorite fishing spot, which is a hike up a steep trail. Oh, and he is in a rate-controlled apartment but is about to lose that, and he is not sure where he can find an affordable place. He can’t afford most medicines either, being on a high-deductible health plan, and he doesn’t want to take them because his mom had diabetes and severe mental health issues, and as a 7-year-old, it was his job to inject her with insulin before and after school, and she lost limbs and was started on medicines that made her “even more crazy.” I let him talk for several minutes, making notes and asking a few clarifying questions. Finally, he stopped talking and looked sheepishly at me.
“See, I am just wasting your time. These things aren’t what doctors care about.”
I disagreed. I showed him his rough list of goals that I wrote in the HPI space of his note. “Which one do you want to work on first?”
Things for Jim did not get better overnight. And his situation is not perfect now. But he did come back for a follow-up and another and another. He still eats mostly fast food, but his A1c has come down to 7.8% with medications he understands and feels comfortable with. He takes his blood pressure medicine, but the CPAP machine is “COMPLETELY OFF THE TABLE, DR. P!” The neuropathy in his fingers did not improve with better diabetic control, but an occupational therapist helped him find an adaptive needle threader so he can still string a lure. He just walked a 5K with his daughter and grandson, though he tells me that he “will NEVER do that again.” Too many people, and “You know how I feel about people.”
I do know how he feels about people because I know Jim. And, yes, I know his medical problem list because that is the system we live in. Got to keep the HCC scoring up to date to keep my bosses happy! But I do not practice problem-oriented medicine. I practice goal-oriented medicine. And it has made all the difference in my patients’ lives and in mine too.
So, come join us! Start making these changes in your practice. They are subtle but profound. We still have a lot of work to do to stop the problem-focus of our EMRs and our health systems, but we can start with our patients in our exam rooms. It is time to take medicine back. Come and join the revolution.
Becky Purkaple is a family physician.