How we can tell that we’re still not patient centered

“The vein rolled.”

This is how the medical student summarized his efforts to place one of his very first intravenous lines in an elderly hospitalized patient. He was successful on the second attempt, but reached for this classic explanation for the first failure. We learn early how easy it is to blame patients when things don’t go the way we expect.  Perhaps it’s how we cope with work in such a high-stakes business. And lest you think we have crested the hill and are on the downhill of this particular thinking, consider the following language recently heard from a resident physician:

“The patient was non-compliant.”

Medicine began the general migration from this term more than a decade ago, but you still hear it frequently when a patient’s response to his or her treatment regimen differs from the provider’s instructions. “Compliance” suggests a matching of patient behavior to provider recommendations.  “Adherence” is the preferred term and implies a match between patient behavior and the agreed upon regimen developed by both the patient and the provider. Adherence suggests that a dialogue has taken place and a set of behaviors (e.g. exercise, diet-modifications, medication) were agreed upon. Even of the patent fails to follow the regimen, at least he was a part of the decision.

There are other ways we reveal the same bias in our thinking. Patients who do not come to their appointments are called “no-shows.”  If they go to the emergency room for care instead, and do so frequently they are called “frequent flyers” or even as I heard recently, “PAUers” (PAU = Potentially Avoidable Utilization).  Interestingly we also tend to villainize the emergency rooms where they get care and the providers who care for them in the ER instead of recognizing their key role in providing patients access to care.

When we objectify patients language like this becomes acceptable. We forget that these are people with stories and refer to them instead as “teaching material” or “fascinomas.” From a business perspective we talk about “market-share” when we really mean people; people who need surgery or hospice, women who deliver babies prematurely, men suffering from prostate cancer. When we agree to see a patient who has come to the appointment late we are “rewarding bad behavior,” with no particular insight into why they might be late.

“They just don’t care” is something I heard recently from a provider. It is a troubling value judgment. And it may be the thought that is most concerning because it reveals how disconnected we have become from our patients’ lives.

American medicine in the mid nineteenth century was provided by practitioners who lived in the community with their patients. Healthcare was delivered in the home. In 1873 there were fewer than 400 hundred hospitals in the entire nation.  The transition to twentieth century medicine was fueled by gasoline. The introduction of the automobile allowed the physician to dramatically increase his productivity and efficiency. The transition was also accelerated by the invention and proliferation of the telephone. According to Professor Paul Starr (The Social Transformation of American Medicine, 1982) the first telephone exchange in the United States was established in 1877 to connect the Capital Area Drugstore  in Hartford Connecticut with 21 local doctors, so patients could contact the doctors and coordinate their visits. Provider efficiency increased but so did revenue, driving an even greater need for efficiency.

The transition has come at a cost and we continue to experience the repercussions.  Again from Professor Starr:

“The doctor of the nineteenth century was a local traveler who knew the interior of his patients’ homes and private lives more deeply than did others in the community. By the early twentieth century, many physicians went to work at hospitals or offices and had little contact with the homes or living conditions of the patients they treated. This radical change in the ecology of medical practice enabled physician to squeeze unproductive time out of their day.”

Unfortunately it also created a distance between patients, providers and health care systems that exists to this day. When patients in our inner city community talk about what they are looking for from their health care system they talk about trust.

The economy of medicine is ultimately relationship, and the currency of that economy is trust.

The vein may well have rolled. But the operator on the other end of the IV catheter is the one with the responsibility to explain why and then to attempt it again. If we can’t get the line we will find someone else who can.

There is a person and a people at the end of the IV needle.

And I suspect they are getting tired of being stuck.

Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.wordpress.com/