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Patient Centered Care, Guidelines, and Peer Review
In previous notes, I have talked about “Patient Centered Care” as one of the attributes of a high-quality system, but I have also talked about how the care we deliver needs to measure up to the guidelines published by various government agencies and professional societies. I have also talked about how peer review needs to be based upon those guidelines. Recently I have been engaged in conversation with physicians who are concerned that these mandates may be in conflict and they may be “dinged” during the peer review process. While I don’t have a simple “rule” to guide physicians through the maze, I do have some notions about effective resolution of the conflict. First, we need to make sure that our assessment of a particular patient’s problem is not “self-referential.” It is the patient’s right to determine treatment options and our obligation to be as honest as we can about the risks as well as the benefits of the various options. As a specialist, I naturally view patient problems from the perspective of my areas of concern first, but my concerns are often not the patient’s concerns. Many publications show that nephrologists do not use “recommended” interventions for coronary artery disease in their dialysis patients. Most of these publications are written from a physician specialty perspective, which assumes that interventions will result in longer symptom free survival. As a clinician who talks to patients about this issue with great regularity, though, I find that many of my patients are hoping for a quick arrhythmia death more than another year of survival on dialysis. Since my mortality rates are published on the Internet and my care is subject to peer review here in the hospital, I have a vested interest in “looking good” on these statistics. However, this is an example of a self-referential perspective. Good peer review, though, should show that I have identified the issues and had a conversation with the patient, often with input from a consultant with expertise on the problem at hand, and we have made a decision to forego further intervention. Making a decision not to follow a guideline is different from not being aware of the guideline, and the writers of all guidelines make it clear that none apply 100% of the time. I hope that electronic documentation in the office and in the hospital will make it easier for us to document these decisions once and then import them into each new encounter with the patient without the need to repeat ourselves endlessly. Much research into guideline use shows that physicians often make conscious decisions to “take the patient off the protocol” for good reason, but often the documentation for such decisions is buried in the chart. Since more and more care is being done by teams of physicians, especially hospitalists, who often do not know the patient, we need to think about making these critical management decisions easy to find and easy to incorporate into the current episode of care. |
Further Reading
Activating Patients - The Achilles Heel of Healthcare Reform? Studies show 25% of the population is not involved in their healthcare, but reform efforts assume wider application of evidence-based medicine is the key to better value. Perhaps it is the Achilles' Heel? Are We Too Task Oriented? The number of tasks doctors must complete grows exponentially. Have we become too task oriented at the expense of our patients? More on Biases A recent series of articles in the New England Journal of Medicine provide more insight into the issue of bias in medical decision making. Putting Patients At The Center Of Healthcare Putting patients at the center is crucial for healthcare organizations, but how can it be done? Risk, Reward, and Other Reasons Patients Don't Follow Medical Advice Patients often don't do what their doctors recommend. The problem is important and contributes to "bad" outcomes, yet we have little insight into the problem. The Limits Of The Medical Model |