Is patient-centered care part of the problem?


What is the difference between a health care system and a Burger King? In a health care system, you can’t always have it your way.

At some point in our training, most physicians are introduced to the Institute of Medicine’s landmark report on Crossing the Quality Chasm. The report outlines 6 key elements that are necessary for providing high-quality care: safety, timeliness, effectiveness, efficiency, equitability and patient centeredness. Although I recognize that outlining the 6 goals is a noble attempt at helping mend a broken health care system, I have to admit that, as a practicing psychiatrist, nothing is more cringe-worthy than the term “patient-centered care.”

Although the IOM’s intended aim in identifying this as a key element was to acknowledge a need to shift away from a paternalistic health care system that often devalues individual agency in order to shift toward a system that is capable of providing care that is “respectful of and responsive to individual patient preferences, needs and values,” the concept of patient-centeredness has unfortunately devolved into something that is anything but noble. Instead of valuing the sacredness of the physician-patient relationship, our misguided attempts at implementing a patient-centered health care culture has inadvertently created an atmosphere of suspicion, hostility and mutual distrust between patients and providers.

One of the major problems with the concept of patient-centeredness is that it is difficult to objectively measure. Most health care systems rely on patient satisfaction surveys as indicators of how successfully they are implementing a patient-centered approach.  The trouble with patient satisfaction surveys is that they are highly subjective and, as a result, inadvertently anti-provider — particularly when they are relied on as indicators of competence or are tied to compensation. Any number of things from expensive parking, to snarky front desk staff, to not being prescribed desired medications and/or interventions that are clearly not indicated for the condition at hand can lead to low satisfaction scores.

I clearly recall a gentleman who presented as a transfer of care from another psychiatric provider who was prescribing a total of 120 mg (twice the FDA approved maximum dose for this particular stimulant medication) of Adderall daily. He was a known methamphetamine addict and had no evidence of ADHD upon continuous performance testing. His history of methamphetamine dependence makes him much more likely to abuse stimulant medication.  No reasonable psychiatric provider would ever prescribe a stimulant in this setting however no amount of rationalization or explanation on my part could stop this gentleman from declaring that I am a miserable excuse for a physician (along with a few other choice expletives) before storming out of my office. Needless to say, my disappointed drug seeker did not provide me with a very flattering patient satisfaction survey.

Although this patient is certainly entitled to express his opinion regarding the care that he received, we cannot allow survey culture to create an environment in which patient preference is valued over the clinical expertise of the provider. We also must not tolerate an environment that allows patients to feel justified in attempting to bully providers into giving them what they want. For medicine to work, both the provider and patient must mutually respect each other.

Another danger of attempting to apply fast food culture to health care is that it leads to the unrealistic expectation that things will always run smoothly, efficiently and according to schedule. When they do not, the provider is left bearing the blame. This situation places providers in a strange double bind. On the one hand, the provider is positively incentivized for providing efficient care that gets patients in and out in a timely manner and ultimately increases productivity numbers.

On the other hand, the provider who takes the time to educate the patient about his or her diagnosis, treatment options and patiently addresses all questions or concerns is negatively incentivized if the time taken to educate the patient happens to run over the allotted time slot. The choice becomes one of running efficiently and risk being perceived as un-empathetic when ushering patients out of the door at the exact moment that the allotted time for the appointment is over or taking the time to patiently educate and empathize with patients but, in turn, risk being perceived as being chronically late and disrespectful of their time by the other patients who are waiting in your office, as well as judged as being “inefficient” by administration.

In other words, as a provider, you are damned if you do and damned if you don’t. What patients fail to recognize is that most providers have a very limited window of time to deal with any number of issues that can range from simple and straightforward to complex and potentially life-threatening.  Although it is understandable that Mr. Smith may complain that his 2:20 p.m. appointment did not start until 2:40, perhaps he would be a bit more understanding if he realized that the person in the appointment slot immediately prior to his was complaining of chest pain and needed to be urgently admitted to the hospital.  We have unfortunately become so focused on our individual needs that we fail to recognize the larger picture. For medicine to work, we need to let go of entitlement.

Given all of the hoopla regarding patient centeredness, I’ve often wondered where the well-being of the physician factors into the equation. According to the 2015 Physician Lifestyle Report, over 50 percent of family practice physicians report symptoms of burnout. This is up from 43 percent in 2013. In his 2011 bestseller, Drive: The Surprising Truth About What Motivates Us, Daniel Pink proposes that autonomy, mastery, and purpose are the three key elements for true motivation and satisfaction in the workplace. The level of self-perceived autonomy has certainly dwindled amongst physicians. Between the ever increasing amounts of bureaucratic red tape, soaring rates of student loan debt and limited control over our patient and even vacation schedules, physicians are no longer feeling that we are able to direct our own lives.

Mastery, according to Pink, involves getting better and better at something that matters. The advent of new maintenance of certification (MOC) requirements is yet another added layer of bureaucratic nonsense that is leading to rising levels of dissatisfaction amongst physicians. The MOC essentially dictates, not only the type of knowledge, but the actual source of knowledge that must be obtained in order to maintain certification as only MOC “approved” coursework will count toward the MOC’s requirements for continuing medical education (CME).

As a practicing psychiatrist, what matters to me is teaching people how they can shift their lifestyle and perspective in order to gain mastery over their own lives. As this shift occurs, many of my patients often find that they no longer need to rely on psychiatric medications. Instead of being able to pursue continuing education that focuses on talk therapy, nutrition, emotional resilience and functional approaches to prevention, I must primarily focus on neurobiologically based CME activities in order to maintain my psychiatry board certification.

Although psychopharmacology is without a doubt an important aspect of psychiatric care, it is certainly not a panacea and does not happen to be a passion for me as an individual. I would much rather pursue continuing education that helps people heal rather than education that helps people remain dependent on psychiatric medications. Unfortunately, these sorts of educational activities do not “count” toward maintaining my certification.

This brings me to the final concept of purpose. It is a basic human desire to want to do work that is in service of something larger than ourselves. When medicine is reduced to a consumer oriented, profit-driven model of care, everyone suffers.  This model drains the life out of providers and actually leads to worsening outcomes for patients. Healers have a much harder time healing others when they themselves are broken. For medicine to work, we must recognize our humanity.

Instead of continuing to champion a health care model that fosters burnout and resentment among providers and encourages an attitude of entitlement, distrust and disrespect among patients, perhaps we should radically shift the current paradigm to one that values human connection over some profit driven notion of good customer service. One of the first steps in this process is abolishing the notion of identifying the patient as the center. We should instead champion a model that places the sacred relationship between patient and provider at the center. If given a choice between snazzy waiting rooms, and appointments that start and end on time or access to a provider whom they perceive as being not only competent, but someone who genuinely values, hears and respects him or her, I can almost guarantee that the majority of patients would choose the latter.

This is why “relationship centered” rather than “patient centered” care is key. Although you can’t always have it your way when it comes to health care, if we choose to work together, we can definitely have it our way. What a wonderful thing that would be.

Reba Peoples is a psychiatrist and founder, Imara Health and Wellness.


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