This is Part 1 of a discussion on the subject of patient access to health records and enlisting patients as partners in healthcare.
From the patient's point of view, a prominent focus of healthcare reform is to more directly interact with and include the patient in their healthcare decisions. While this is a laudable goal, there are a number of hurdles that need to be cleared in order to make this viable. I believe there are at least five reasons why most patients are not good partners when it comes to healthcare decisions for themselves or loved ones:
Patients come to a physician typically only after a disease or process has progressed to the point that it is no longer comfortable for them to ignore it. This distress, by itself, puts the patient at a disadvantage for making judgments and assessing importance.
In a number of recent articles, including one this week called “Questions every ER patient should ask,” patients are being urged to ask if a specific treatment or examination is actually required. I would submit that in many cases patients are under such duress, even for what a physician may consider a relatively negligible concern, that decisions made regarding specifics of care will, in many cases, be flawed from the beginning.
When faced with any significant issue, particularly one affecting health, most patients move relatively quickly through the phases of grief, from shock to denial. Feelings like, “it's not that bad,” or, “that doctor doesn't know what he's talking about,” are common. Denying the disease itself or the cause of the disease frequently leads to treating symptoms and not the illness. The patient becomes their own worst enemy as a healthcare partner because they cannot objectively assess their own disease process. In addition to distress, denial further adds to the likelihood that bad decisions will be made.
When presented with different options for therapy or diagnosis, cost is frequently never discussed. When it is, the more subjective idea of the "value" of each alternative is more difficult to convey. This is because physicians and other providers have spent years in school trying to get a handle on just that question.
There are many alternatives to treatment and diagnosis, and each patient presents a different set of issues where the clinician or provider must choose the correct management course or tools to address these individual issues. Because the patient has not undergone this education, explanations of different alternatives can lead to additional distress and concern as the patient tries to both understand the information and make choices based on this incomplete understanding. Throw in significant differences in cost, between, for example, a skull series, a CT scan of the head and an MRI of the brain, and the patient will frequently make a choice for the most expensive examination as being the best.
Patients, armed with the latest Google search present themselves to their provider with a complaint list and everything they "know" about their illness. Physicians can have difficulty sorting through what is true or reasonably true versus the latest ad, wrapped up as real information.
With little or no background, how will a patient sort through the information to direct their healthcare? The provider is faced with the issue of both removing bad information and educating the patient with the appropriate information on their illness. The patient presented with conflicting information from the Internet and from their provider now has to make a determination as to what is true. How is the patient in distress, in denial, unsure as to the cost or value of any treatment or diagnostic procedure supposed to use conflicting data to positively affect their healthcare?
From the pharmaceutical standpoint, many patients believe that a big pill is better than a little pill or little pills are more potent than big ones. More milligrams is better than fewer milligrams — even if the medications are completely different. And finally, a pill that costs more is better unless it costs too much and then it is worse.
From the radiology standpoint, patients are now being told that their diagnostic examination will lead to cancer — at least that's what many remember from the latest media blast. The idea of ALARA, As Low As Reasonably Achievable, never enters a conversation. In ALARA terms, sometimes the highest dosage radiology examination is the one with the most value. The exam with the least value and lowest cost frequently has the lowest dose and sometimes it's a mixture of highest cost — lowest value or lowest cost moderate value.
Next week’s discussion will be: How to Make Patients Healthcare Partners.
Tim Myers, MD, is a practicing radiologist and director of professional services at vRad (Virtual Radiologic). He has more than 15 years of private practice experience and served as the chief medical officer for NightHawk Radiology Services before its merger with vRad.