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Monday Oct 03, 2016

Patient Preference, Priorities Should Matter

When I heard that Atul Gawande, M.D., was going to be speaking at the AAFP's Family Medicine Experience (FMX) in Orlando, Fla., I got the kind of rush of excitement that most people get when their favorite band is coming to town or their team makes the playoffs. I was ecstatic. 

There are not enough authors in medicine who help guide us as physicians through the ethical and emotional hurdles we all face. And I have yet to find another author who rivals Gawande's compassion and interest in the patient's perspective of the health care experience.


Kirk Ackerson/AAFP News
Atul Gawande, M.D., signs copies of his book, Being Mortal, during the Family Medicine Experience in Orlando, Fla., where he was the keynote speaker Sept. 21.

On the day of his speech, Gawande had a signing of his book Being Mortal, and I was second in line. I was behind a woman who shared my star-struck attitude. She had a surgical cap that her boyfriend was hoping she would bring home autographed. Not only did Gawande sign the cap, he replied to an email thanking him for signing it, which made me realize he doesn't just analyze patient relationships, he values people and their priorities.

Gawande's latest book delves into the workings of nursing homes, why they were created and why they don't meet the needs of our seniors. The place where many of us will live our last years may not value how we want to spend that time or how we spent our entire life getting there. Examples include patients with diabetes and dementia who are denied comfort foods because of safety issues, separating patients from their pets and limiting patients' freedoms overall. 

Before I left for FMX, I had multiple experiences that echoed the themes Gawande wrote about in his book and discussed in his keynote. As I've mentioned in previous posts, my community suffered a devastating flood in June. A significant component of caring for the flood victims is tending to their mental health. The loss of  material possessions took a toll, but the loss of routine and place has been much more detrimental. 

The Federal Emergency Management Agency has offered housing alternatives in the form of apartments in Charleston, W.Va., which is at least an hour away, but not in the rural areas where people in my community have built their lives. The only option offered was entirely unacceptable to most people here because it didn't take into account the factors most important to them -- familiarity and autonomy.

I had a fourth-year medical student working with me a few weeks ago, and at the end of the day, I realized the theme of that day wasn't a diagnostic breakthrough or a lesson in medical management or anticipatory guidance. I quite literally had told multiple patients to refuse treatments, to argue with subspecialists and to make their own decisions about their health care. 

A grandmother of one of my infant patients asked me if, theoretically, she transferred care to me, would I accept her as a patient if she refused to get a colonoscopy? Another one of my patients who is paraplegic refused a heart catheterization after a non-ST-segment elevation myocardial infarction. Rather than arguing with him about the importance of opening up one of his coronary arteries, I simply asked him why he didn't want the procedure and what he wanted me to do if/when his heart failure started to progress.

My practice has large bar graphs representing each provider's quality data hanging on the wall that all of the patients can see as they exit the building. I have yet to top the list on any of the charts, but it's not for lack of trying. I like the concept of moving toward a value-based payment system. But, as Gawande pointed out in his keynote speech, we family physicians tackle invisible problems that aren't rewarded appropriately. We are collectively frustrated with the metrics against which we are measured because despite the attempts to improve our payment system to date, they continue to miss the mark. 

There is no way to meaningfully measure patient-centered care because it depends on patient preference. Paying me based on colon cancer screening rates is misguided if it means I'm screening patients who are neither candidates for colon cancer treatment nor willing to undergo any treatment if a cancer were found. We've got to remember that regardless of payments, rankings, evaluations and bar graphs, what we do for each patient needs to be compatible with that patient's goals and values, especially in end-of-life care.

Improving the overall health of a community is obviously important. It takes a lot of motivational interviewing to get a patient with diabetes on board with a diet plan to drop an A1c from 12 to 7, and we have to push patients to adopt healthier lifestyles, but not at the expense of their dignity. We have to help people within the framework of their own reality. 

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va. You can follow her on Twitter @BecherKimberly(twitter.com).

Posted at 01:55PM Oct 03, 2016 by Kimberly Becher, M.D.

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