Does Patient Centered Care add to ER Overcrowding?
Posted by CEP America on Tue, Mar 02, 2010 @ 06:44 PM
By Prentice Tom, MD
In a recent issue of Health Affairs, (28, 4, 2009: w555-w565), Dr. Don Berwick makes an argument for Patient Centered Care, where physicians rely on patients to make informed decisions regarding diagnosis and treatment plans. He states:
"Evidence-based medicine sometimes must take a back seat. First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. Should patient ‘wants' override professional judgment about whether an MRI is needed? My answer is, basically, ‘Yes.' On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase ‘a fully informed patient.'"
I agree with the concept that it is critically important to have patients involved in their care and be part of the decision making process. And as physicians, we need to strongly encourage patients to take an active role in their health maintenance and disease management. Over the last twenty plus years of practice, I have found that by informing and educating patients and their families regarding their medical condition, diagnostic and treatment options, and by seeking their input regarding their health goals and their expectations, I am much better able to serve and care for my patients.
Still, there are times - especially in the emergency department - when this approach may not be in the patient's best interest, nor the best interests of overall patient care. Unfortunately, in the emergency department, where time and resources may be severely limited, the emergency physician may be required to provide care in a manner that most efficiently utilizes resources and maximizes patient outcome, even though the patient may want a test that is not necessary for treatment or the physician may not have had the opportunity to fully explain his/her decision.
In a physician's office, clinic, or in-patient ward, care that's truly patient-centered considers patients' cultural traditions, personal preferences and values, family situations, and lifestyles. But in the emergency department where beds are scarce, resources are limited and the patient has no prior relationship with the physician, we need to balance patient education and demand for limited resources with overall patient flow, and the type of patient-centered care that Dr. Berwick describes may not be the best solution.
It is likely that every emergency physician can recall seeing a patient similar to the one that Dr. Berwick describes: Doctor, I have a headache, and I want an MRI. Access to an MRI can take multiple hours in a busy hospital, and even explaining why we can't offer such testing can take many minutes. In principle, I agree with Dr. Berwick. But in a system where the patient may not bear any financial responsibility, and where resources and time are limited, Such a practice may not always be in the best interests of overall patient care. I only wished I lived in a world where emergency physicians had the time and resource availability to provide patient centered care to all our patients.
I would appreciate your thoughts or experiences with Patient Centered Care in the emergency department.