Improving Patient Care Delivery

This is part one in a series of posts on person centered care. A version of this content recently appeared as a guest post: “The center of gravity in health care and the role of primary care” on KevinMD.com. A recently recorded podcast episode on the guest post is also available here.

I’ve been as guilty as anyone of leaving my patient out of the process. As a practicing primary care physician, I’ve had patients with diabetes who observe Ramadan, and I had no idea how to support and manage them during their fast. I’ve had transgender patients for whom I didn’t feel I had the right language to talk about their health and nothing in the electronic health record seemed designed. I have so many times sent patients out the door with a referral, knowing they would struggle to navigate our convoluted healthcare system, which even veteran insiders like me cannot master.  The U.S. healthcare system excels at many things, but patient-centeredness is not one of them.

I often find myself frustrated with how “patient-centered” our healthcare system is not. I remember being a medical student tagging along on inpatient rounds. A gaggle of residents, interns, and medical students followed an attending physician from room to room, talking to each other about each patient openly – often in front of other patients – as if the patient weren’t even there. Even as a medical student, my intuition told me “something is not right about this” – but it was what everyone did. 

In fact, so myopically has the U.S. healthcare system organized around its own needs that the patient seems to have been an afterthought. The birthplace of this dynamic is in the traditional treatment model, where medicine has historically been very paternalistic, placing the patient as a passive recipient of care provided by experts who know best. 

While this started with the traditional treatment model, it was made much worse by the fee-for-service payment system, which incentivizes doing more things instead of getting better results. With these two factors working synergistically, it is no surprise that patients have been peripheralized and rendered a commodity.

This passive role played by patients has since been proven less effective, and studies show that “patient-centeredness” improves not only the patient experience but clinical outcomes as well. As it turns out, giving patients autonomy in their care is THE key to patient engagement, and patients who are engaged participants in their care are healthier, live longer, and have better quality of life. But the cultural shift of moving the U.S. healthcare dynasty from physician paternalism to patient autonomy has been ambitious, considering how deeply these have manifested in systemic behavior and policy.

Perhaps in an effort to reclaim agency over their own healthcare, we have seen a rebound into what is known as patient consumerism. The internet has created easy access to unlimited medical “information,” and it isn’t uncommon for a patient to tell me what tests to order and what medications to prescribe. I take care to work collaboratively with my patients, to educate and empower them with information, and to be a partner in their healthcare decisions. However, misinformation is increasingly rampant, targeted ads for drugs and services drive product demand, and deference to the training and expertise of physicians seems to be an unnecessary courtesy for some. It can be frustrating and time consuming, and I sometimes bite my tongue in the urgent care setting to stop myself from saying, “How about we let me be the doctor today?” 

This trend reflects justified backlash against a healthcare system that has completely disempowered patients and destroyed their trust in our intentions and abilities.  Patient consumerism isn’t the disease – it’s a symptom of a hypofunctioning healthcare system which has run away with itself and left patients disillusioned and taking matters into their own hands.

Dr. Sara Pastoor is a family medicine doctor practicing in innovative primary care models for the last twenty years, with a focus on patient-centered medical home and health system transformation. Dr. Pastoor spent the first 15 years of her career in the Army Medical Department serving in various leadership roles supporting Army medicine’s transformation to a patient-centered system for health. Currently the Director of Primary Care Advancement for Elation Health, Dr. Pastoor spends time advocating for the powerful role of independent primary care physicians and the value of using a clinical-first electronic health record (EHR) platform. She is also Co-Director for Presence Health, a direct primary care practice in Austin, Texas.