This insecurity is the biggest challenge in my practice: getting people to change their behavior. Somehow I have to somehow get people to pay attention to their health when they'd rather ignore it, to be taking medications when they'd rather not, to be exercising when they don't want to, to lose weight when they love cheeseburgers, and to be checking their blood sugars when they'd rather not know how high they are. After trying lots of things over the past 20+ years, the one thing I find almost never works is what is usually done: lecturing the patient.
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If you look up the word "compliance" in a thesaurus, the first synonym (at least in my thesaurus) is "obedience to." This implies that non-compliant patients are, at least to some degree, equivalent to disobedient patients. This is borne out by the reaction many patients seem to expect of me when they "confess" they haven't taken prescribed medications: they look guilty — like they are expecting to be scolded.
The real question I am asking here is not if this care is good or bad (the answer to that is, yes, it is good and bad), but whether it is patient-centered.
This should be a silly question, like asking if car-repair is car-centered. But it is clear that much of the high cost of care in our country is due to the huge number of unnecessary procedures, medications, hospitalizations, and services given to/done on people. Unnecessary care is, almost always, not patient-centered.
The vast majority of people truly want a doctor they respect and actually like. This may come as a shock to many of my jaded colleagues who routinely face the ire of people stuck in waiting room purgatory, ignored or disbelieved by doctors, and treated as objects instead of people. They think that people are angry because they don't like doctors. They view the people on their schedule as, at best, the hungry masses they must placate and, at worst, as their adversaries they must conquer. Then they wonder why their patients are so unhappy?
The past three years has taught me otherwise. People want to like their doctors. We just haven't given them any reason to do so.
Rather than dwelling on the malfunction of the system, however, I want to turn my eyes toward what most people don't see: what real patient-centered care could and should be. It's not that I am suddenly wiser than my colleagues in the sick-care system. Despite 18 years in practice, I was not able to see what true patient-centered care looked like until I left the system.
When I say we need more tech, I am not saying we need more computerization so we can produce a higher volume of medically irrelevant word garbage. I am not saying we need to gather more points of data that can measure physicians and "reward" them if they input data well enough. The tech I am referring to is like that I used regarding my father. I want technology that does two things: connects and organizes. I want to be able to coordinate care with specialists and to reach out to my patients. I want my patients to be able to reach me when they need my help. Technology can do this; it sure did for my dad.
He seemed a bit grumpy when he came into the office. I am used to the picture: male in his early to mid-forties, with wife by his side leading him into the office to "finally get taken care of" by the doctor. Usually the woman has a disgusted expression on her face as he looks like a boy forced to spend his afternoon in a fabric store with his mother. My office is the last place he wants to be.
I've been going about this all wrong. It's not my dumping of the payment system so I can focus on care over codes, my use of technology to connect better with patients, or my vision of the "collaborative record" that is wrong. It's the fact that I am doing this without my most important resource: my patients.
I realized this while driving in to work this past week. My first patient was a tech-savvy guy I've known for a long time. Not only does he know me, and knows more than me about technology, he also is a regular reader of this blog (bless his heart)...and he still chose to switch to my practice! So I was looking forward to running some of my ideas by him to see if my thoughts have strayed to the land of silliness (which they often do) or if I am actually onto something. This line of thought led me to think about collaborating with him to work on my IT vision, since he does work for an IT company. My line of thought then careened into the brick wall of the obvious: why just him? I've been getting suggestions and offers for help from many of my patients, who are clearly intrigued by my direction and desirous to lend their expertise on the project. So why not involve any of my patients who want to be part of this project?
So this morning I sent out an invitation to all of my current patients:
Many of you know that my biggest frustration at the moment (besides congress) is the total lack of software that supports a practice like mine. I have a vision for what I need, but right now that is only possible using multiple tools in different places. In other words, it's confusing and chaotic -- something the old way of doing health care was good at, but something I am trying to avoid. As I've worked to figure out what to do with this project, I've been getting lots of offers for help and suggestions on what to do from some of my patients. It occurred to me recently (not sure why it didn't sooner) that I need to involve you, my patients, in the building of this system. First off, you are real smart (as witnessed by your choice of doctors, of course), and could give me significant insight and help in this area. Second, these are your records, and I believe this whole thing won't work unless I build something that works for you. Here's what I need:
- A "brain trust" of patients who can help me get to the best solutions in this area. I need a group of folks who know software/databases/IT (or who are good at faking it, like me) to discuss, brainstorm, and possibly build the tools that will work for both me and my patients.
- A group of folks willing to test various tools (Twistle is an example of one of those tools), and give me their opinions on what is good/bad/ugly about them.
We can meet in person, but since this is a geeky thing, I suspect most of our meetings will be held in the far reaches of cyberspace. If in the end we come up with an ingenious piece of software, I have no hesitation but to share the piles of cash that fall out of the sky on us. I don't really care about that side of things, actually. I really just want a system that will let me take care of all of you most effectively.
If you are interested, please let me know.
I am not sure why I hadn't thought of this earlier (except that my mind is still affected by the "doctor is the center of the universe" reality-distortion-field that our wonderful system perpetuates). The truth is, my patients have as much if not more at stake in this project. They want me to succeed because that success will mean better care for them (and that I can stay in business and not move to New Zealand to wait for my Medicare Opt-Out period to end). Many of them have joined me because they share my vision for care that is better for patients, better for doctors, and saves money. Besides all that, anything I build won't fly at all unless it works for them.
So I've started on this new project: the true collaborative health record. It's important to me because it enables me to run the system as well as possible. I believe my model of care can only succeed if supported by an infrastructure to support it, but that with that infrastructure, it can become a viable alternative to the spend-care, sick care system both patients and doctors hate.