Recently I wrote about empowerment
and the importance of letting patients make their own health care decisions. Our job is to make sure patients are given information
and then allowed to choose the best option for them. Maybe we should even embolden
patients; give them confidence and encourage them to take more control. Physicians
tend to feel more comfortable advising according to the “standard of care” and we
struggle handing over the reins when we believe we “know” the safest path to
take.
Every time I talk about building better metrics, I
emphasize the significance of evaluating something physicians can change or control. The intent behind measuring patient
satisfaction was likely to increase patient autonomy, however, as with many things;
the devil was in the details. It turns
out chasing higher patient
satisfaction scores can result in higher costs
and increased mortality. Overall, the most satisfied patients were more
likely to be admitted to the hospital and total health-care costs were 9%
higher. Most strikingly, for every 100 people who died over a four year period
in the least satisfied group, 126 people died in the most satisfied group. At least they died happy and satisfied right?
That notion can be difficult for some physicians to accept but might be more
important than we realize.
Looking at surveys Press and Ganey developed over
their illustrious careers leaves me wanting something more than “Did your doctor
listen to you?” and “How often were you treated with courtesy and respect by
your physician?” Neither attribute ensures better health care outcomes as noted
above. If the goal is to empower
patients, more objective questions are necessary to give more insight into this
metric.
1. Did
your physician give you a name for your condition? (“I don’t know” counts.)
2. Did
your physician discuss more than one treatment option?
3. Did
your physician ask you to choose a treatment for your condition?
4. Did
you ask a question of your physician? How many?
_________
(CMS bonuses $ per number of questions >1.)
5. What
did you learn during your appointment with your physician? (Use lines below and
there is more space on the back if necessary.)
A few
winters ago, I had my opinion handed to me on a silver platter. A new family with a 4 month old baby came in
for a well child check-up and immunizations.
The mother mentioned concerns about a cough her son had for 7 days. On exam, he was afebrile and well hydrated;
yet, had raspy breathing that troubled me.
On exam, that observation translated into bi-basilar crackles with
slightly decreased breath sounds on the right side. Without a fever, a chest x-ray seemed like
the best option to differentiate between bronchiolitis (not worrisome) and pneumonia
(more distressing.)
The
mother picked her child up off the table and looked horrified at my suggestion to
order a film. Fear and hesitation over an X-ray was a novel response, however I
had seen this reaction about immunizations, blood draws, or other significant interventions
before. I inquired as to her concerns
and reassured her radiation exposure was minimal compared to the risk of
missing pneumonia in an infant. We went
back and forth with a more questions and answers. I always try to be
kind, courteous, open, direct, and honest and this situation was no different. This mother did not want an antibiotic prescription and I
was uncomfortable treating the baby with antibiotics and no definitive diagnosis. She ultimately refused any further care,
picked up her son, walked out the door, and went home.
This
child was not necessarily on death’s doorstep, but I could not guarantee this
child would get better on his own. I
communicated as much to the mother; she disagreed and it was her right to do
so. I explained my concerns, conveyed my
recommendations clearly, and discussed symptoms she should watch for if the
baby worsened. I documented the
encounter in the chart and there was nothing more for me to do.
After
the mother left, the student shadowing me that day began crying out of shock, disbelief,
concern, and frustration at this mother for not doing the “right” thing. I remember feeling this way years before: there was always a right answer, it was our
job to find it, and make things happen, but health care does not always work
that way. As a physician matures, they
begin to understand more of the gray.
The
practice of medicine is an indefinite, sometimes clumsy art and as a result can
be unpredictable as a science. While it
is difficult for physicians to comprehend, what we believe to be best for our
patients may not be what they feel is best for their children or themselves. It is a bitter pill to swallow. We spend years in training witnessing good outcomes
with intervention and death from “poor” decisions, but we must remain cognizant
of the fact each patient may have a different goal.
Patient
satisfaction seems to come less from the ultimate outcome, and more from
feeling acknowledged and having played a role in health care decisions. That is the key to true empowerment and
autonomy. Consider how this mother might
have answered the survey questions. She would have been “satisfied” despite our
disagreeing, which makes for a better metric upon which to evaluate
quality.
Patients are weary of being told what is best for
them, what they should do, or what standard of care dictates. Unfortunately, I have lost children as a
result of parents not following some recommendations a few times in my career. In
reality, I may have lost them regardless.
Here is where the rubber meets the road: The autonomy to choose the right path for a
given patient may have dangerous and permanent consequences, but the authority
lies with them for better or for worse.
A patient may be very satisfied one moment and dead the next. It is time physicians embrace the fact that our
aim and conduct should be to inform and educate, not to convince or influence
and let the chips fall where they may. And
survey metrics should objectively reflect the importance of that vital patient concept.
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