Patient-Centered.
It sounds so right, doesn’t it? Right up there with mothers and apple pie. If only family medicine were so simple.
A report by ABC news told the story of a doctor at a VA hospital in Kansas City who claims she was forced to leave her job because she tried to limit prescriptions for opioid pain medications to reasonable amounts. Patients complained, so she was canned.
She claimed that some patients received prescriptions for 900 narcotic pail pills a month. Some patients were “lethargic, not functional.” Patients who wouldn’t accept the gradual tapering of the narcotic doses would threaten her, “cussing, cursing, lashing out, complaining to the administration … .”
In a separate announcement, the VA admitted there’s a problem with opioid prescribing nationwide and says it will improve the situation in part with “physician education.”
From a different environment comes stories of ER doctors prescribing Vicodin “goody bags” for patients complaining of any sort of pain. This approach decreased patient complaints and increased patient satisfaction scores, so hospital administrators were giddy.
These reports come in the midst of other findings that deaths from prescription drugs are now greater than deaths from heroin and cocaine combined.
The PCMH pushers have it wrong. They push for high patient satisfaction scores the way a retailer would obsess about customer satisfaction ratings. Unfortunately, my world in family medicine is so much more complex than running a Target.
We shouldn’t focus exclusively on patient satisfaction. We really need system-centered care by system-centered physicians. Most of the time this will correlate perfectly with patient satisfaction: patients who feel like they were listened to and that their physicians simply cared for them. But at key moments, the highest form of family medicine is to piss off a few patients. Those who demand narcotics for iffy indications, demand antibiotics for colds, and demand MRIs for simple sprains are but just a few examples. This isn’t to suggest that the family docs should be jerks about the encounters. There are polite and tactful ways to say no. But no matter how nicely it’s said, if a patient has made up his mind that he will not be satisfied until he gets his narcotic, he will leave the physician encounter not just dissatisfied, but often burning mad.
The PCMH pushers make no acknowledgment that these types of encounters occur and make no effort to reward ethical family physicians for making good decisions to protect patients from harm to themselves and protect the medical commons for everyone. In fact, they have created incentives for physicians to do the wrong thing.
This is one more reason the current PCMH model should be dumped into the trash heap of innovations that just didn’t work.
You said a mouthful. Last month’s issue of Texas FP, the editor and president commented on should your patients like you. The patients only like you if you do what they want and if you don’t they will find one that will. Some of my colleagues are worried about continuity of care; patients are only happy if they get the antibiotic or narcotics. My patients don’t want to be told their diabetes, blood pressure or obesity is out of control. So what is the answer. I make the right choices for myself. Why can’t my patients do the same.