Friday, January 2, 2009

What Does it Mean for the Patient to be in Charge of their own Health Care?

Robert Veatch's book: Patient Heal Thyself: How the New Medicine puts the Patient in Charge is reviewed in the December 25th issue of the New England Journal of Medicine. Of two of Veatch’s main points, one is correct and one misses the point entirely. The first point: “Patients alone are in charge and have no choice but to assume this role” is correct and is essential to any patient's aspirations to stay healthy. After all, physicians' recommendations are worthless unless the patient understands, accepts, and follows them. So, if that doesn’t make the patient in charge, I don’t know what does! Any notion that the physician is "in charge" is more the physician's fantasy than anything else. A physicians role is not to be in charge of the patient's health, but to use their training and experience to guide the patient and to help coordinate their care and, in some cases, to directly provide some of that care.

Even more passive patients, who prefer to relegate decisions to the physician, are really still "in charge" in the sense that they are choosing not to question recommendations made or seek a second opinion. While it is true that many patients just don’t feel they have the resources or the information to do this, the internet has shifted the balance and now makes it possible to effectively and objectively research almost any medical question.

The second point, that “physicians will no longer be seen as capable of knowing what will benefit their patients” inappropriately relegates the role of the physician to a technician or an information resource. In truth the physician, by himself, has never been in a position to determine the best choice for the patient any more than a lawyer can determine what sentence a plea bargaining criminal can choose rather than going to court and taking a chance with the jury. The patient/client must do that.

But, there are a wide range of approaches that patients and clients use to arrive at decisions, whether they be health care, investing, legal, personal and otherwise. Wise ones inevitably choose their own course after appropriate due diligence. But there is a wide range of variability on how they go about this, from those who still prefer that their doctor make their decisions for them to those who simply want to do the research and have the doctor provide the support to proceed along their chosen course of action.

Most patients end up somewhere in the middle, whether that be in the office or through an online dialogue, and would like to at least hear the opinions of a trusted health care professional and use that information to help them make a decision. If someone is going through a painful divorce and needs legal help, does she prefer to go to the internet, pull up the relevant state law and tell her lawyer what to do? No! She prefers to tap his judgment and experience to make recommendations in response to which she makes a considered decision and moves ahead.

This is no different from the appropriate role of the physician: to enter a relationship with the patient, listen to their story, investigate their problem utilizing their training and experience, assisted by health care technology, then provide recommendations and then do it over and over again, many, many times, as often as the patient needs them to.

I believe the primary reason that this doesn't work as well as it should is because too many of us maintain the illusion that we are still in control of the patient's health and seem to think that status quo needs to be maintained.

So, what lessons does Mr. Veatch's book leave with us? In my opinion, it is a good wake up call for physicians. We need to embrace the "ePatient Revoution", recognize that the patient MUST be the one who is in control of their own health care, assist them in achieving this, and not be tempted to allow that to interfere with our professional self esteem because, in my view, it in no way threatens it!

Your comments and dissenting opinions are welcome.


Anonymous said...

Amen. I agree with your assessment wholeheartedly, Dr. Smith

The problem we patients run into is that disconnect between knowing in our heads that we should take responsibility of our health and medical care, and finding a doctor that buys into it, too.

Yet -- if the doctors would buy in -- I believe both patients and professionals would benefit.

Thanks for your thoughtful post.

Trisha Torrey
Every Patient's Advocate

Charles Smith, MD said...

Dear Trisha,

Increasingly, patients will walk from doctors who don't "buy in".

Thanks for your comment.

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