Improving the health outcomes of older adults with multiple chronic morbidities has been my calling as a physician. During residency, my colleagues were interested in difficult, rare, or novel cases. In contrast, I was attracted to the lingering, multiple everyday conditions that older adults faced. I was also struck by the fact that providing all the recommended screening and treatments for each of their conditions often did more harm than good. It became immediately clear to me that my role as a clinician was to partner with my patients. In the end, it was the patient and her family that had to identify health and life goals, prioritize which of those goals were most important, and then work with clinicians to find treatments that best aligned with one’s goals and values. From this perspective, “non-adherence is a dysfunctional concept.” The quintessential signs of poor quality of care for multimorbid older adults, e.g., polypharmacy, overutilization, adverse events, often result from a discordance of values and goals between clinicians and patients.
Based on these formative experiences as a newbie physician, I chose to focus on patient-centeredness as a distinct dimension of healthcare quality and identify pathways in which patient-centeredness leads to patient engagement, collaborate goal-setting and improved health outcomes. More recently, I’ve explored the ‘patient experience’ itself. Appreciating how someone experiences illness, healthcare, changes in health status and personal growth has profound impacts on how we understand healthcare quality. Policy experts and researchers often view quality through the lens of expertise, large datasets, and multivariate analysis. While this perspective has its merits and applications; assessments of quality for most goods and services is intuitive, normative (value-based), and socially constructed. Therefore, we cannot improve healthcare quality without patient engagement; which means communicating about health and healthcare in ways that make quality intuitively conscious to the everyday patient. There are many clinicians, policy experts, patients, and caregivers who think that only experts can judge quality. This perspective is anachronistic—a vestige of a professional view more consistent with a medieval guild rather than the 21st century industrial complex healthcare has become.
This absurd perspective—that patients cannot or should not be asked to understand and judge healthcare quality is the principal cause of hyperinflation within the American healthcare system. It is ironic that Ford and Apple can create immensely complex products and then ask people of all stripes to judge quality and make high dollar purchases without first taking a crash course in automotive engineering or computer science. There are no screening tests for literacy of the internal combustion engine or static random access memory chip. From this vantage, patient-centeredness exists when patients can intuitively judge the quality of their chronic illness care just like the quality of their smart phone. As a first step, patient-centeredness is an approach that engages the patient experience, focuses patient-clinician discussions on the needs of patients, and opens the door to conversations about values and goals. The next step is an alignment of treatment priorities with one’s goals and values and then selecting and judging specific treatments that meet those priorities. Along the way, we will need novel approaches to communicating about and grasping the inherent value of health services and treatments. This brave new patient-centered world does not diminish the role of clinicians. The key to improving the health outcomes of our older patients (and the overall quality of our healthcare system) is through re-investment in dialogue between patients and clinicians and a strengthening of trust within the patient-clinician relationship.
This post originally appeared on the GeriPal blog.