Tuesday, September 27, 2016

Building Better Metrics: Focus on Patient Empowerment

Growing up during the 1970’s and 80’s, the “Little House on the Prairie” television series was an iconic part of my childhood.  Doc Baker was the physician and veterinarian for all of Walnut Grove, in spite of limited resources.  Medical lessons were everywhere in the beloved television series:  Mary experiencing onset of blindness (most recently attributed to viral meningoencephalitis, likely from Measles), the death of Laura’s infant son by unknown cause, and Rose’s survival after smallpox infection.    

When patients ask me how to start solid foods, how to get a baby to sleep through the night, or how to treat minor injuries or burns, I frequently wonder if they would have asked the town doctor these same questions one hundred years ago.  Probably not, because they would know to watch their baby for hunger cues, let infants cry it out at night, or slap some egg white, aloe, or honey on their wounds or burns to prevent infection back then.  Empowering patients to treat themselves where appropriate has tremendous value to cut down on cost and consumption of precious resources.  It was also how medicine was practiced more than a century ago.

The other night I was reading comments of a local mom group on social media, when a question came up about how to treat thrush while breastfeeding.  A patient’s mother commented they should use gentian violet; paint their own nipples and their infants’ mouth lightly as well.  A mom asked, “What is gentian violet?” This mother discussed its antibacterial and antifungal properties and its topical use for oral candidiasis.  I felt a huge sense of pride watching her share knowledge with other mothers.  The cost of a 1oz. bottle of gentian violet is currently $3.69. 

Crystal violet (aka gentian violet) was first developed in 1883 by Alfred Kern; it is still listed today by the World Health Organization as a valuable topical antiseptic agent.  Gentian violet has antibacterial, antifungal, anthelminthic, and antitrypanosomal properties. Today, it is used for:  Marking the skin for surgery preparation, treating Candida albicans and related infections, such as thrush, yeast infections, tinea, jock itch, ringworm, and even Impetigo, primarily before the advent of antibiotics. Educating mothers on thrush and the use of gentian violet occasionally helps them avoid seeking care when unnecessary. 

Patient-centered care is often talked about as a virtue worthwhile to attain because it puts them at the heart of their healthcare team.  Empowerment goes one step further by actually giving power and authority to the patient.  It is a very important concept that is often missed in the world of big-box medicine today.  There is actually an organization devoted to this concept called the European Network on Patient Empowerment (ENOPE.)  According to them, an empowered, activated patient:

  • Understands their health condition and its effect on their body.
  • Feels able to participate in decision-making with their healthcare professionals
  • Feels able to make informed choices about treatment.
  • Understands the need to make necessary changes to their lifestyle for managing their condition.
  • Is able to challenge and ask questions of the healthcare professionals providing their care.
  • Takes responsibility for their health and actively seeks care only when necessary
  • Actively seeks out, evaluates and makes use of information.

Empowering patients to care for themselves with shared decision making is the reason my doors are still open.  Fee-for-service can be a fiscally valuable model because for one office visit, a patient can receive diagnosis, treatment, and education from a single professional.  Physician ownership encourages patient empowerment because it prevents doctors from spinning their wheels needlessly.  There is no benefit to seeing a patient over and over for the same chief complaint. We want our schedule open for other patients who need our help.  To avoid the journey overwhelming burnout, we need to lighten the load in our offices. 

Over the last century, health care has morphed from a system valuing individual responsibility to one grounded in physician dependency.  Patients are viewed as clients who ravenously consume scarce resources, while physicians dispense answers and guidance for a price deemed too high by bureaucrats to be sustainable.  Knowing how invested patients are in understanding their conditions and their willingness to take responsibility for their good or bad choices are metrics worth tracking. It is important to remember physicians make recommendations, educate their patients, and would do best by engaging in shared decision making with those patients.  That entire process saves money and improves how patients view their quality of care. 

A 3 year old girl came in with a history of 3 days of vomiting this week.  “I have been pushing oral rehydration solution with a syringe like you taught me,” she said.  Her mother knew how to check for signs of dehydration using urination frequency and a few other tricks I have taught over the years.  She knew when vomiting persisted in spite of proper rehydration attempts, it was time to bring her daughter in for evaluation. Her child had lost less than 0.5kg due to her mother’s excellent care and diligence.  I could not have been more proud and shared that with her.  At this point, it was reasonable to prescribe her a medication to reduce nausea and vomiting, but no ER visit was necessary because this mother had confidence in her skills to care for her child properly, and if she needed her PCP, she knew I would be there. 

Better metrics must be about being better able to empower our patients.  They are tired of being told how to birth their children, how to immunize them, how to lose weight, quit smoking, or exercise more, and how to treat their elevated blood pressure and cholesterol numbers.  I am not suggesting we stop sharing our expertise and making recommendations based on good science.  However, patients want to make their own informed choices and we need to let them.  Doc Baker had it right.  Take another look at his practice model in “Little House on the Prairie.”  A system incentivizing self-reliance is far more sustainable in the future and is where we should strive to be.


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