Monday, January 7, 2013

Who's in Charge Here?


This week’s issue of the New England Journal of Medicine has two “Perspective” pieces having to do with decision making and the difficulties that modern medical advances and modern health policy advances have inadvertently created.  I read these and can only think of the immortal words of Oliver Hardy talking to Stan Laurel saying, “Well, here’s another fine mess you’ve gotten me into”.  In our zeal for ever more expertise that comes with medical specialization and for ever more organization for our unorganized system, have we created a “fine mess”?   Are we losing the ability to help our patients make choices that are consistent with their own values and in keeping with the best medical knowledge?

The article by Stavert and Lott entitled, “The BystanderEffect in Medical Care” accurately compares the problem of having multiple specialists to the bystander effect which is the human tendency to be less likely to offer help in emergency situations when other people are present.  Poor communication and coordination between medical professionals can lead to each physician only being focused on the specific disease they are involved in treating and not the entire patient.  The old concept of the primary care doctor being the “captain of the ship” has given way to primary care doctors who no longer even enter the hospital and leave that care to the hospitalists, intensivists, and other specialists.  For complex outpatients, the primary care role can quickly devolve into a triage role.  The specialists who are focused on their small piece of the puzzle often don’t truly coordinate with the primary care physician.  The primary care physician is so busy just seeing patients that the coordination and the compilation of the facts and opinions gleaned from the specialists often never happens.   Even if the coordination happens, it is then never communicated to the patient and the family.  The authors suggest mechanisms to improve communication between individuals’ clinicians by supporting initiatives such as the TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), an initiative developed by the US Agency for Healthcare Research and Quality.

The article by Oshima and Emanuel entitled, “Shared Decision Making to Improve Care and Reduce Costs” points out that the Affordable Care Act (ACA) calls for greater use of shared decision making in health care and that the implementation of that part of the law has stalled.  They call for more use of decision aids and more use of incentive payments to encourage providers to better use those decision aids and for funding the development of better shared decision making tools.  They make the strong argument that a good starting point is to begin with are the 20 most frequently performed procedures and to require the use of decision aids for those procedures.  They further argue that full Medicare and Medicaid reimbursement should be contingent upon those decision aids being used. 

I find myself reading all of this and agreeing with the analysis but wondering at the same time, if the cures for the two diseases of “bystander” effect and lack of shared decision making are leading us into a morass of forms, requirements and process that will do little to really solve the problems.  The bystander effect, while suggesting the need for better teamwork still requires a single person who feels ownership of all of the patient problems.  Traditionally that single person has been the primary care doctor.  But putting more pressure on the primary care doctor to do all that coordination, compilation of results and opinions, and communication is hard to reconcile with the challenges of primary care practice.  The primary care physician still has to evaluate, diagnose and treat while seeing more and more patients and having less time with each patient.  I, like others, hope the medical home initiatives and the ACO movement brings incremental improvement but for me and my family, I also hope that I always have one person I trust who will be by my side whatever my problem or problems may be.  That person may or may not be the doctor.  In our system at Accolade, we have developed a new profession; that of Health Assistant, who communicates, educates, coordinates and advocates while not diagnosing or treating.  They take the time to be the one person at the patient and the family’s side during the duress of illness.

While decision aids may be necessary for better shared decision making they are in no ways sufficient (and the authors do not suggest that they are sufficient).  Many patients and their families just do not have the skills to use those resources most effectively.  They are often riddled with the anxiety and depression that comes with illness that prevents good use of such tools.  They often have real barriers that have to do with family, financial and work concerns among other types of “non-medical” issues that prevents them from making the best choices.  I wonder if requiring a provider to hand someone a booklet or asking a patient to watch an interactive video will make all the difference.  I have my doubts even as I acknowledge that these tools are useful when used together with other communication and support techniques. 

In this mix, we need more humanity.  We need more caring.  While more tools and systems certainly will help, I doubt that they are the whole or even the most important parts of the answers we seek.