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Patient-Centered Care Versus Patient-Directed Care


We have all experienced patients who demand certain tests or treatments and see the physician’s role as rubber-stamping whatever is desired. Here's how to deal.

Patient-centered care seems to be a popular buzzphrase among policymakers and administrators in recent years. Indeed, many physicians see our healthcare system as payer-centric, many patients see it as physician-centric, and no one seems to see it as patient-centric.

While putting the patient at the center of what we do as physicians is critical to improving the triple aim of better care, better health, and lower costs, it is important to keep in mind what this exactly means.

Patient-centered care is not the same as patient-directed care

We have all experienced patients who demand certain tests or treatments and see the physician’s role as merely rubber-stamping whatever is desired. This is a common trait among millennials, but also older generations who now have access to all sorts of information, both correct and incorrect, through the Internet.

Though these patient requests are sometimes accurate and warranted, they often go against medical evidence or our clinical judgment as physicians.

The example often given is of a patient with a viral upper-respiratory infection who demands antibiotics. Many physicians fear negative patient satisfaction scores or losing a patient in a competitive market, and so will prescribe the antibiotics as the patient requests.

This has obviously negative ramifications for antibiotic resistance and poor care, but these are the incentives that have been set for us by many payers and administrators. It is only human nature to follow the incentives.

Patient-centered care does not have to be something that compromises our practice.

Patient-centered care does not mean physicians must give full decision-making autonomy to the patient, just as routine care does not demand that the physician provide full-decision making.

It has been shown that many patients who demand certain care, such as antibiotics when not warranted, do respond to proper communication and explanations of why it is not merited. An acknowledgement of their desires is critical, but an informed discussion of why the request is not appropriate should occur.

This is actually the definition of patient-centered care - allowing the patient to make an informed decision together with the physician. A respectful, trusting relationship obviously improves this discussion and the patient's willingness to listen to medical evidence and expertise, but even more acute settings where a long-standing relationship has not been established can be successful in these aspects.

Challenges physicians face due to patient-centered care

The problem inherent in this advice is that physicians' schedules and time with patients are being squeezed. How can we expect patient-centered care, patient satisfaction, quality of care, or even physician satisfaction, when the system has been moving toward less face time with patients and more administrative duties for so long?

It’s quicker to write a prescription than to take time to explain to a patient why the prescription isn’t necessary.

Many of us feel that payers and administrators are setting us up for failure by providing incentives to increase RVU production while also providing incentives to improve quality and provide patient-centered care. These two goals often seem contradictory.

The trusting relationship with patients is being undercut by competing demands, lessening the likelihood of satisfying the patient. This then contributes to a payer-centric and perceived physician-centric way of caring for patients.

Hence, dissatisfaction among physicians, many of whom desire to leave the profession.

True patient-centered care can actually improve the quality of care and decrease the cost of unnecessary and potentially harmful testing and treatments. Hopefully, proposed payments that incentivize team-based care and move away from fee-for-service will provide the ability to spend more time educating patients, both by the physician and by ancillary team members.

While physicians are not merely around to sign off on anything a patient wants, the discussion, trust, and education of patients moves the perception of care from patient-dictated to patient-centered.

That may mean losing some patients who absolutely demand having what they want, but it will also strengthen the bonds with many patients in your practice. After all, that is the reason so many of us entered medicine in the first place.

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