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Patients As Partners

The famous late 19th and early 20th century physician, Sir William Osler, said that “a physician who treats himself has a fool for a patient.” How would he have felt about patients diagnosing and treating themselves? Would he have written in support of the Journal of Participatory Medicine or against it? I also wonder how he would have practiced medicine in the “information age” when many of our patients present with a diagnosis already made, right or wrong.

I recognize that bringing Dr. Osler into a discussion set in the information age is, perhaps, anachronistic. Yet I believe he still has something to teach the 21st century on the topic of patient participation. When he advised that “the first duty of the physician is to educate the masses not to take medicine,” he offered one of the earliest lessons on a physician’s role as educator.

He also said: “The great physician would treat the patient with the disease while the good physician would treat the disease.” For me, this marches lock-step with the reality of today’s patient as consumer and active participant in the doctor-patient relationship. Simply put, it is impossible to separate the patient from a pre-conceived and often well-researched opinion — correct or not. So to treat the “patient with the disease” requires me to think of my patient as an intellectual partner. Read more »

The Government’s Involvement In New Primary Care Models

Government healthcare reform efforts are picking up the pace to roll out new reimbursement and practice models for primary care.

Medicare is giving out $10 billion for pilot projects encouraging new models of primary care, including the patient-centered medical home. New Jersey just passed legislation to explore the patient-centered medical home. Now, Massachusetts, the early adopter of mandatory health insurance, is now ambitiously planning how to take on the fee-for-service reimbursement system and moving toward accountable care organizations. Under discussion are the scope of power for state regulators, what rules will apply to accountable care organizations, and how to get rid of the existing fee-for-service system.

Blogger and pediatrician Jay Parkinson, MD, MPH, comments about the “bureaucrats in Washington” that, “they’ve decided for doctors that we’ll get paid for strictly office visits and procedures when, in fact, being a good doctor is much, much more about good communication and solid relationships than the maximum volume of patients you can see in a given day.”

Now, it’s those same bureaucrats who are changing the system, trying to find a model that will accomplish just those goals. (CMS Web site, NJ Today, Boston Globe, KevinMD)

*This blog post was originally published at ACP Internist*

Medical Errors: Discuss Them Or Switch Doctors?

Patients won’t confront doctors if they think there’s been a mistake. They’ll just find a new doctor, even if there’d been no medical error.

Researchers looked at adult visits to seven primary care practices in North Carolina during 2008. They asked patients about their perceptions of medical mistakes and how did it influence the choice to switch doctors.

Of 1,697 patients, 265 (15.6 percent) reported a mistake had been made, 227 (13.4 percent) reported a wrong diagnosis, 212 (12.5 percent) reported a wrong treatment, and 239 (14.1 percent) reported changing doctors as a result. Results appeared in the Archives of Internal Medicine.

But anecdotes cited by patients as mistakes were often normal diagnostic or therapeutic challenges. A typical scenario might be the patient reported symptoms, the doctor did not correctly diagnose it at first presentation, and a specialist or second physician offered a specific diagnosis. Other scenarios included medication trials or side effects from the prescription. Read more »

*This blog post was originally published at ACP Internist*

Dealing With Medical Error Together

The “Running A Hospital” blog has another discussion of dealing with medical error. This time, the hospital has opened up an error of its own (a “wrong side” surgery) for examination by the Open School of the Institute for Healthcare Improvement (IHI).

Sample comments:

— From IHI’s Jim Conway: “Our systems are too complex to expect merely extraordinary people to perform perfectly 100 percent of the time. We as leaders must put in place systems that support great practice by people who suffer from being human and will make mistakes.”

— From a patient who had two surgical errors in ten months: “After years of suffering through our incredibly brutal tort(ure) system I finally had the chance to talk to the surgeon. The most meaningful words he spoke were the descriptions of how badly he suffered also from the event we shared in that OR. Finally I was not alone!”

As we’ve often said, participatory medicine brings a new kind of partnership between patient and caregiver. Neither denial nor a Wall of Silence (famous book) has any place in a healthy relationship. It breaks my heart to think of the good lives that are ruined by our cultural inability to deal with honest errors in complex situations.

Yes, as Linda Kenney of MITSS mentions in a comment, some employees (in any industry) are reckless and must be weeded out. That too can be a denial issue. But first, we need open discussion.

*This blog post was originally published at e-Patients.net*

Doctor-Patient Relationship Humanized By Touch

I’ve written previously that many doctors are finding the physical exam obsolete, and are favoring more technologically-advanced, and expensive, tests. In fact, I alluded to traditional physical exam advocates as “arguing for staying with a horse and buggy when cars are rapidly becoming available.”

In a recent piece from the New York Times, internist Danielle Ofri says we need to look past the lack of evidence supporting the physical exam. The benefits of touching the patient, and listening to his heart and lungs, cannot be quantitatively measured:

Does the physical exam serve any other purpose? The doctor-patient relationship is fundamentally different from, say, the accountant-client relationship. The laying on of hands sets medical practitioners apart from their counterparts in the business world. Despite the inroads of evidence-based medicine, M.R.I.s, angiograms and PET scanners, there is clearly something special, perhaps even healing, about touch. There is a warmth of connection that supersedes anything intellectual, and that connection goes both ways in the doctor-patient relationship.

Great point. Read more »

*This blog post was originally published at KevinMD.com*

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