I recently went to the Asia Pacific Forum on Quality in Health Care, in Auckland. This event was put on by Ko Awatea and the Institute for Healthcare Improvement. What I found interesting was that in addition to issues around efficiency and evidence-based medicine, there was also a strong focus on patient and family involvement and collaborative care.
In some follow-up reading after the conference, I came across a short article by Swensen et al from the NEJM 362.5 (Feb 4, 2010) called “Cottage Industry to Postindustrial Care – The Revolution in Health Care Delivery.” This article argues that the concept of what constitutes a “good doctor” is changing. Currently, to be a “good doctor” means “swimming upstream against the system, rather than relying confidently on it.” This reminds me of my writing on creating a holistic medical practice; the clinician relies on a standard of professionalism that is not always supported by the systems in which clinical work occurs. The article arrives at a contrast between the “good doctor” of the past and of the present.
“In the past, a stereotypical good doctor was independent and always available, had encyclopedic knowledge, and was a master of rescue care. Today, a good doctor must have a solid fund of knowledge and sound decision-making skills but also must be emotionally intelligent, a team player, able to obtain information from colleagues and technological sources, embrace quality improvement as well as public reporting, and reliably deliver evidence-based care, using scientifically informed guidelines in a personal, compassionate, patient-centered manner.”
The components of emotional intelligence, systems focus, collaborative care, compassion, and patient-centered approach are hallmarks of holistic and integrative philosophies.
I was just reading a continuing education article called, “Improving Quality of Psychiatric Care: Aligning Research, Policy, and Practice,” by Kelli Harding and Harold Pincus (Focus, Spring 2011, Vol. IX, No. 2). The authors state that in our current health care system in the US, the “problems are so widespread that trying harder within the current system is not enough. System-wide change is needed.” The authors mention the Institute of Medicine’s 10 Rules for Patient/Consumer Expectations of Their Health Care (adapted below from To Err is Human: Building a Safer, Health System, 2000). Again there is a contrast between the old and the new:
|Old Rules||New Rules|
|1. Care based on visits||Continuous Healing Relationships|
|2. “Do no harm”||Safety is a system property|
|3. Professional rules greater than System||Cooperation and Collaboration between clinicians and institutions|
|4. Decisions based on training and experience||EB decisions without variance|
|5. Professional autonomy drives variability||Individualization, customized care|
|6. Professionals control care||Patient as source of control, shared decisions|
|7. Decisions based on training, experience||Shared knowledge, free flow of information|
|8. Clinicians react to events||Anticipation of needs|
|9. Secrecy is necessary||Transparency in system performance|
|10. Cost reduction||Value or continuous decrease in waste|
Again, we can see that the focus of holistic and integrative medicine on individualized, patient-centered care, collaboration, preventative medicine, low-cost lifestyle modifications vs. high cost pharmaceutical interventions, and on the therapeutic value of a positive therapeutic relationship, all appear to have a prominent place in the new health care revolution, which the authors call a “paradigm shift.”
One area of creative tension between the new quality health care revolution and the holistic & integrative medicine revolution is the variable to time. We know that there is an association between shorter visits and malpractice claims, (Wendy Levinson et al., “Physician-Patient Communication: The Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons.” JAMA, Vol 277, No. 7 (Feb 19, 1997): 553-559). We also know that it takes longer to support behavioral and lifestyle change than it does to write a prescription. We also know that time spent on preventative medicine saves time later as well as money, which is a quality issue. It may be that the quality revolution may make time for clinicians to spend more time with patients in certain circumstances in order to provide less expensive, safer, higher quality care. This is a long-term savings and is more efficient in the long-run, but in the short run it will cost more in clinician time spent with patients.
Creating a health care system that is quality-based, efficient, safe, and cost-effective is a challenging task and countries all around the world are struggling with this problem. It will be very interesting to see how the current health care revolution in quality, in the US, plays out and whether principles of holistic, integrative, and preventative medicine find a prominent place or whether efficiency and evidence-based pharmacological interventions take a more prominent place. During the last time of health care revolution, the Clinton plan in the 1980s, I was a medical student and had a chance to take an elective in health care policy and law. That revolution largely left the doctors out of the loop. Competition was supposed to solve the problem. Ten years later I was working at a multi-specialty group that went to a “eat what you kill” reimbursement policy. I understood the concept, but I couldn’t believe I was hearing this language used by the people in health care systems.
As a student, I remember reading that competition in health care is only cost-effective if there is a population of around 200,000. There then followed a map of the US showing all the regions with less than that population and I realized that system of reform would not work. This time around, it seems that many doctors are embracing the revolution and are more involved in the process of change. At least the language of compassion, collaboration, and continuous healing relationships has at least a linguistic place in the current revolution.