The fallacy of patient-centered care

I often wonder what it was like before patient-centered care became a mainstream catchphrase. Was there a poor relationship between the patient and physician in the outpatient setting? Were hospitalized patients’ feelings, desires, goals, and therapy options ignored? It amazes me that we were able to care for patients more than ten years ago without using a “patient-centered” approach.

According to NEJM Catalyst, “Patient-and family-centered care encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan … Under patient-centered care, care focuses more on the patient’s problem than on his or her diagnosis. Patients have a trusted, personal relationship with their doctors …”

Historically, patients have had better relationships with their physicians than they do today. Today office visits are short to fit in as many patients as possible, and during the visit, the provider is too busy typing into an electronic medical record than looking the patient in the eye. Years ago, physicians made house calls and spent more time discussing what interested their patients. In smaller communities, patients even called their physicians at home if they had a question.

Marcus Welby, MD has been replaced with UltraSuperSpecialized, MD. Our knowledge of medicine, genetics, pharmacology, and immunology has exponentially expanded, but it has come at a great cost. Fragmented care is what we have today. Patients are referred from one specialist to another often with little education regarding how all the pieces of the puzzle fit together. Patients are supposed to take ownership of their health care under this new model. As a physician, I have watched my father go from nephrologist to cardiologist to urologist and then the hospital with urosepsis. Now there was a hospitalist on the case who tried to piece together what had happened with multiple specialists over the past two years. Multiple tests were repeated, new specialists were consulted, and new medications were added.

My dad was finally discharged but not before I had spoken to each specialist to coordinate his care and come up with a treatment plan. He had no “ownership” of his health care. He trusted his physicians to treat his condition and get him home as soon as possible. When a patient is admitted with sepsis or appendicitis or an acute myocardial infarction, how are they expected to play an “active” role in their care? Maybe they should “Google” their condition and review the current treatment options with their care team?

Patient-centered care is a form of value-based care. Governmental agencies and insurance companies are using these new care models as proxies for quality. Since quality is difficult to measure, a patient’s experience or satisfaction with the care provided serves in its place. Unfortunately, we are focused doing what makes the patient and their family “satisfied” as opposed to treating their condition.

As health care providers, we are not in the hotel and restaurant management business. We are here to heal. The fallacy of patient-centered or value-based care is that it forces us to allocate resources on an outcome that has little to do with the true quality of care provided. Is the patient a customer, and as a customer, is the patient always right? One has to merely look at the current opioid crises to see the error in that logic.

Myles Gart is an anesthesiologist.

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