Monday, April 22, 2013

The Person, Not the Patient

"Who the person is with the illness is usually more important than what illness the person has." Sir William Osler.

A recent article entitled "Patient -Centered Decision Making and Health Care Outcomes, An Observational Study" in the Annals of Internal Medicine by Saul Weiner and his associates at the University of Illinois shows, to quote the article, "Attention to patient needs and circumstances when planning care is associated with improved health care outcomes". Not only does it lead to improved health outcomes but also to lower costs according to another recent article by that same group published in British Medical Journal Quality and Safety. While in Weiner's work there are many implications related to our health care challenges of high costs, difficult access, and variable quality, I also found within the findings of the research a return to the wisdom of William Osler quoted above.

Osler also said, "The good physician treats the disease; the great physician treats the patient who has the disease". Weiner , in his work, has found a way to measure the great physician. He has developed a research tool to determine if the physician (or nurse or other health professional) is trying to find out "who the person is with the illness" rather than only "what illness the person has" in the words of Osler.

Before describing that research tool an old joke bears repeating. A man is walking down the street late at night and sees another man on his hands and knees under a street light. The first man asks the man on his knees, "Are you looking for something?". The man on his knees replies, "I lost my keys" to which the man walking along responds, "Lucky you lost them near this light". The man on his knees says, "I didn't. I lost them about half a block from here". The upright man then asks, "Why are you looking over here?" The man on the ground answers, "Because this is where the light is".

Weiner and his group are not just looking where the light is, which is what many do when they limit research to claims databases and even medical records. Weiner audio records visits between doctors and patients to discover the true interaction and to discover how often the doctor is investigating the context of the person's medical problem. In his research, Weiner has defined ten elements of context and he and his staff listen to these office visits to determine if the doctor has asked about the person's life and values and whether the doctor has tried to find ways to remove the barriers to good care that the life context may have created. The ten elements, or domaines of a patient's context are access to care, social support, competing responsibilities, relationship with health care providers, skills and abilities, emotional state, financial situation, cultural beliefs, spiritual beliefs, and attitude towards illness. The researchers then use a standardized survey instrument, with multiple listeners independently rating the visits, to detemine the number of errors made in eliciting the "context" from a patient and in addressing that life context. Using this technique and survey tool they have shown that understanding the person who has the disease leads to good, and efficient care while just paying attention to the disease itself is hazardous to the patient's health.

One of the more recent studies, published in 2010 found that if a patient had no significant contextual issues, doctors provided appropriate care 73% of the time. If there were contextual issues that were missed then appropriate care was given only 22% of the time. The costs were significant as well, as described in the BMJ Quality and Safety journal article. They found that these contextual errors on average increased the cost per visit by $234. Medical errors in comparison increased the cost an average of $164 per visit. In total, the visits they recorded and assessed for errors by audio recording wasted $174,000 due to the errors while the errors found by chart review alone accounted for $8,700 in waste. Yet the bulk of the work in health policy and in managed care is related to the medical and not the contextual and is based almost entirely on claims review and chart review rather than actual recording of visits.

This leads to another quote by Osler: "Variability is the law of life, and as no two faces are the same, no two bodies are alike, and no two individuals react alike and behave alike under the abnormal condition, which we know as disease." Yet we keep believing that standard medically focused algorithms that hold doctors accountable to do the same thing with each patient are the answer to our health care dilemma of high costs and inconsistent quality. Don't misunderstand. The algorithms and the technology greatly improve the science and are welcome and necessary. However they may have an unintended consequence of worsening the art of treating the individual by focusing too strongly on steps in medical therapy even when the context makes those steps difficult or impossible. Both knoweldge of standard algorithms and of a person's life context are critical to good patient care. Osler understood this and now Weiner has demonstrated Osler's wisdom using experimental methods and scientific techniques.

As Osler also said, "Medicine is a science of uncertainty and an art of probability". Weiner has shown that the individual's values, family, finances, faith, emotions and everything else that makes that person a complex being must enter into both the science and the art for good, efficient care to take place. I doubt that can be accomplished by technology and evidence based algorithms alone. It also requires caring professionals helping people in need. We must either give our doctors and nurses the time, training and tools to "diagnose and treat" the context or develop new professionals, as we at Accolade are doing, to address these individual and population based clinical, financial and human needs.