After Michael Michael was diagnosed with colon cancer, he underwent three rounds of chemotherapy — without success — at Massachusetts General Hospital. Then he and his wife were faced with a major decision. They sat down with Michael’s oncologist, and were encouraged to talk honestly about their values as a family and how they would like to spend the time they had left together. Their doctor explained each of what he believed were their options, laying out the risks and benefits. Michael could participate in a clinical trial or try radiation treatments, neither of which would likely prolong his life and both of which probably would make him more miserable. Or he could stop treatment. In that conversation, “our focus shifted to his remaining quality of life,” says Carol Michael. “My husband wanted to finish the play he was writing.” They chose to tap Mass General’s palliative care service, whose doctor would keep Michael out of pain and alert so he could spend his time writing at home. He died there five months later, in 2010.
[See: 10 Questions Doctors Wish Their Patients Would Ask.]
The Michaels’ experience was an early example of “shared decision-making,” a partnership of patients and their physicians at the core of recent efforts to improve care quality and safety. The concept of formally making the patient an active partner in choosing a medical path began spreading widely in the aftermath of a 2001 Institute of Medicine report bluntly pointing out that the health system “has fallen far short in its ability to translate knowledge into practice” and calling for patient-centered care “ensuring that patient values guide all clinical decisions.” In 2017, the definition was expanded to include families as well as patients.
What does this mean for people grappling with a diagnosis? The traditional next steps — you go see a clinician who often unilaterally prescribes treatment based on what is known to work for patients with similar conditions — are giving way to conversations in which the doctor explains, probes and listens while you ask questions and explore which course of action best meets your needs. If as a physician “you don’t know what matters to a patient and what that patient is going through, you cannot possibly know if you are practicing the best medicine,” says Dr. Albert G. Mulley, Jr., managing director of Global Health Care Delivery Science at Dartmouth and a leader in the field of patient-centered care. Services free to patients at Dartmouth-Hitchcock Medical Center include web-based and paper educational materials about treatments, counseling by health coaches who help families weigh their choices in light of their values and assistance with end-of-life planning.
[See: HIPAA: Protecting Your Health Information.]
Shared decision-making isn’t necessary or even possible if there is one treatment, and it is needed urgently. But a man facing early prostate cancer, for example, might be offered surgery and/or radiation or the choice to wait and see. In deciding what course to take, he may weigh whether it is more important to avoid the risks of surgery so he can remain sexually active or to be surer of living cancer-free.
Hospitals doing the most thorough job of involving patients have buy-in from the top, notes cardiologist Dr. Steven Horowitz, medical director of Planetree, the patient-centered care system at Stamford Hospital in Connecticut. There, he says, every new staff member, from doctors to cleaning staff, participates in a full-day orientation to better understand — and learn to improve — the patient experience. A council that includes patients and family members meets regularly to review current procedures from the patient’s viewpoint.
[See: 14 Things You Didn’t Know About Nurses.]
For patient-centered care to take hold everywhere, financial incentives will have to change, experts note. The traditional payment model rewards physicians for rapid-fire visits and quantity of procedures, not quality of care. Instead, the system ought to pay them for “the kind of in-depth communication required to learn what is most important to a patient,” Mulley says. That may be possible if the shift from a fee-for-service model to one focused on value plays out as planned.
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You and Your Doctor Will Be Partners originally appeared on usnews.com
