What Right Care Means to Me: The Physician’s View
Two physicians describe how they are mobilizing patients, providers and others, to change the culture of overuse in health care, to one that is individualized, compassionate and just.
The end of life can be fraught with emotion and excruciating decisions for families. It is a time when overuse of treatments and interventions occurs far too frequently. The culture of medicine teaches physicians to “do everything you can” to keep patients alive, with an underlying message that more is better when it comes to treatments and interventions. For doctors, patients and their families, making the decision to refuse extraordinary measures can feel like giving up.
As physicians who are active in the Lown Institute’s RightCare Alliance, we are dedicated to changing this culture. We know that a range of practices persist as standards that don’t improve the length or quality of life. Overuse and inappropriate care are baked into how we do things to the point that they are almost invisible. From frequent blood draws in the hospital to unneeded imaging for a normal pregnancy and futile chemotherapy in end-stage cancer, our goal is to keep patients safe from unnecessary diagnosis, treatment, and ultimately, harm. We think that it is critical to combine an understanding of the true benefits and risks of procedures and therapies with a respect for a patient’s wishes. Such a thoughtful approach that individualizes care, promotes doing more for the patient and less to the patient.
This is RightCare Action Week, and we are encouraging physicians and patients to take part by documenting and sharing experiences of overuse or inappropriate care, and raising awareness of issues that are increasingly urgent as medicine becomes more high-tech and invasive, and people live longer. We have identified three RightCare action areas: overuse counts, story slams, and photo shares. But we are eager to hear about other ways people are participating.
For individual clinicians, actions can be as simple as taking a deeper social history: for example, asking people about their fondest aspirations or some major life-changing experience will give clinicians a deeper understanding of who the person in front of them really is. Similarly, having a conversation about end of life preferences or stopping to think before reflexively ordering a test could each play a role in fostering a new way of seeing and doing things.
So far, we have partnered with several organizations on RightCare Action Week, including the National Physician Alliance, the Committee for Interns and Residents, and the Institute for Healthcare Improvement, and thousands of doctors are following our campaign.
At Erie County Medical Center in Buffalo, NY, for example, the Chief Quality Resident is sharing the article "Tyranny of Guidelines," just published in the Annals of Internal Medicine, with her fellow residents during ActionWeek. “Tyranny of Guidelines” tells the story of an 86-year-old Minnesota man who went from healthy and living independently to disabled and residing in a long-term care facility after doctors prescribed a litany of medications designed to bring various lab results into the “normal” range. The article is meant to get the Erie County residents thinking this week—and beyond—about how important or relevant quality metrics actually are to their elderly patients. At the Lown Institute, we believe that quality care is not just about correcting lab results, but respecting the values and culture of patients and their families. In that vein, residents will be encouraged to have meaningful conversations with their patients over 80 that address such questions as: Do you want to continue living independently? Would you risk dizziness and the risk of falling to bring down blood pressure? Is it worth quality of life tradeoffs to take insulin and other medications to lower an A1C level that won’t budge?
There are lots of other grassroots efforts cropping up around the country during RightCare Action Week. Medical students in Virginia, Denver, and San Francisco are holding story slams where they share their experiences with overuse and inappropriate care. In Boston, Dr. Saini and Dr. Aaron Stupple are setting up “Listening Booths” with the goal of capturing people’s voices in order to shape a better health care system. Some questions the doctors will be asking:
- What do you want from health care?
- What do you wish your doctor could hear?
- Do you have a story of overdoing it?
- What would be the “Right Care”?
Going forward, the RightCare Alliance is organizing committees in primary care, palliative care, psychiatry, surgery, and others to foster peer-to-peer conversations and recruit others to document the most significant areas of overuse, underuse and inappropriate care. We will continue to urge clinicians to engage patients and respect their values when making decisions about care. We plan on publishing our findings, stimulating discussion and the power of one-on-one conversations to move the health care system away from the “more is better” paradigm that encourages overuse and harmful interventions.
RightCare Action week is just the beginning of what we hope will be nothing less than a culture change in how our nation views compassionate, just, health care.
Vikas Saini, MD, is President of the Lown Institute. Read his full bio.
Kathleen Grimm, MD, is a physician at the Center for Hospice & Palliative Care and co-chair of the Community Health Worker Network of Buffalo, NY.