Trendspotter: Patient-Centered Care Depends on Resources

The patient-centered medical home (PCMH) has a fairly big glitch, it turns out. According to the TransforMED report on its national demonstration project (NDP) for the medical home, patient satisfaction with the process of care actually declined in most of the family practices that pioneered the concept from 2006 to 2008. 

Here’s what the TransforMED press release about the report says:

“The NDP evaluation team reports it is possible to implement the NDP model in highly motivated practices, but in most, doing so seems to worsen patients’ perception of care, at least in the short term. The PCMH model must continue to evolve in a way that practices can make changes that are desirable in the long-term, but not at the expense of personal relationships with patients and other functions that are already providing good value. PCMH recognition and certification processes also should focus more on patient-centered attributes and the proven, valuable key features of primary care than on the features of disease management and technology.”

In a KevinMD.com post on this finding, Steve Wilkins, a former hospital executive and a consumer health behavior researcher, attributes the decreased patient satisfaction mainly to poor patient-doctor communication. Despite the increased emphasis in medical homes on technology such as secure e-mail and Web portals, he says, “there is no evidence in the TransforMED pilot of substantive efforts to improve the quality of the dialogue between physicians and patients.” He suggests that physicians need to find out more about each patient’s circumstances and spend as long as is needed to answer their health questions.

Well, those are noble goals, but ones that are unlikely to be achieved in a typical primary-care visit - whether or not the primary-care physician is attempting to become a medical home. Physicians tend to interrupt patients while they’re telling their stories and cut to the chase because they’re under extreme time pressure. If they don’t see enough patients per hour, they won’t make a decent living.

Some of the commenters on Wilkins’ post cast aspersions on the medical home concept. They maintain that it adds complexity and documentation time that detracts from patient care and that the “care teams” required by the medical home fragment the care and make it more difficult for patients to see their physician.

But I think these people are missing the point: it’s not care teams that are the problem, but how they’re used.

One commenter, Christine Sinsky, MD, points out that in her practice, other members of the care team assume responsibility for the tasks that she doesn’t have to do, allowing her to focus on the most difficult and important parts of patient care. “The nurses prepare the patient and the physician by organizing the data ahead of the appointment, helping the patient set their agenda, and taking responsibility for the standardized, predictable work of the practice, such as immunizations and cancer screening,” she notes.

In addition, although Sinsky doesn’t say this, nonphysician clinicians can play a key role in patient education and follow-up. And information technology - which goes far beyond patient-doctor e-mail - may include electronic registries and other tools that help care teams track patients’ health status and make sure that they receive the services they need.

Sinsky argues that the main drivers of patients’ satisfaction are their ability to see their personal physician the same day for acute needs and being able to get the majority of their care from the same physician. Many patients do feel this way - and in fact, both of these criteria are principles of the patient-centered medical home.

But again, we need to leaven these laudable goals with a pinch of reality. The fact is that primary-care doctors are scarce in many areas; so patients may be able to get better care by forming a relationship with a nurse practitioner or a physician’s assistant in a primary-care practice.

I had my eyes opened in this regard recently, when I moved from one state to another and had to find a new primary-care doctor. When I called one of the practices that accepts my insurance, the receptionist told me: “You can get an appointment with one of our doctors in about three months, but if you have a pressing problem, one of our nurse practitioners will see you.”

Well, I suppose I will eventually see my new doctor, if I choose that practice. But this is not what I expect from a physician-patient relationship. I suspect that many other people feel the same way, but that’s not the real world in 2010.

Patient-centeredness, like every other aspect of healthcare, depends on the available resources and how they’re used. While physicians’ willingness to see their patients’ point of view is also crucial, there’s not much they can do if they don’t have the time or the staff they need to give every patient the attention they deserve.