A guest column by the American College of Physicians, exclusive to KevinMD. Engaging personally with our health care system either as a patient or family member is usually an eye-opening experience for most physicians. It provides a glimpse of what those under our care likely deal with on a daily basis while attempting to manage their health. And what we see often isn’t pretty. My most recent personal medical “reality-check” has been as the physician child of two very elderly parents who have encountered significant cognitive loss, progressive frailty, and the need for long-term care on their individual journeys toward the end of life. Thankfully, their overall care has been provided by kind and compassionate individuals who patiently and lovingly deal with the many difficult challenges associated with the slow, painful loss of both mental and physical functioning each has developed. And for this, my family and I, and I’m certain my parents (were they able to express it), are truly appreciative. However, as their lives and health issues have evolved, I’ve struggled with how the health care system – the very system of which I am a part – has dealt with managing their progressive decline. As my parents have accumulated the comorbidities of advanced age, in many instances, the medical care offered to them has seemed significantly “detached” from their actual needs and wants, the individual circumstances affecting realistic goals of care, the likely outcomes of different interventions, and possibly their best interests. I’m referring to things such as continued treatment of chronic, stable conditions (such as hypertension and hyperlipidemia) in a manner focused at preventing potential complications many years into the future; recommending extensive evaluation of minor, asymptomatic, and likely age-related, non-life-threating abnormalities often incidentally discovered on laboratory testing; requests by care staff for acute evaluation (usually involving transport to another facility) of vague, mild, and usually transient symptoms or complaints; and the tendency to want to provide aggressive treatment for things such as a mild cough in the context of normal vital signs and clear chest examination with an extended course of broad-spectrum antibiotics out of fear for possible pneumonia. And there are many more examples. Although many of these potential medical interventions might be technically indicated and are certainly well-intentioned out of concern for the wellbeing of very frail individuals, it is clear that they are also fraught with possible unintended consequences and at their worst could lead to possibly unnecessary harm in these quite vulnerable people without a clear benefit related to their eventual clinical outcomes or quality of life. As a physician, I have the luxury of understanding the potential benefits, but also the significant harms, associated with different medical interventions, and also know what my parent’s wishes and desires would be for their own care. So while trying my hardest not to be “that” physician child who annoys everyone by seeking to micromanage their relative’s medical care, at times, I feel as though I’m compelled to “protect” my parents from my own system by more assertively intervening in their medical decision making than seems necessary. And I know that my experience is not unique. In talking with other physicians, they also acknowledge the significant challenges involved in navigating the health care landscape either with their own medical issues or those of relatives. Most are impressed by the difficulty they experience in ensuring patient-focused, rational, coordinated, and safe care despite having intimate knowledge of how things work within their own system. I can only imagine the experience of patients and their families who don’t possess this knowledge and ability to effectively advocate for themselves or their loved ones in engaging with the health care system. I’m in no way suggesting a “nihilistic” approach to medical care – as an internist, I fully believe in applying the best that medical science has to offer to the benefit of our patients as aggressively as needed given the appropriate clinical circumstances. But rather, these personal experiences highlight the need for us as physicians to seek to apply our medical armamentarium in a more individualized, nuanced way that considers both the context and trajectory of our patient’s lives. In some ways, I believe we are victims of our own success. We can do so much more for our patients than at any previous time in history, and our training is oriented towards doing everything we can for each patient. Coupled with increasing specialization, subspecialization, and fragmentation of health care in terms of who provides it and where, it seems as though we frequently apply our medical knowledge almost mechanistically – that certain clinical factors trigger a set of interventions that need to be done in order to provide optimal, evidence-based medical care. However, this approach runs counter to the traditional, fundamental responsibility of the physician to tailor the care provided to individual patients based on an understanding of their wants, needs, clinical conditions, and likely outcomes, and doing so in a thoughtful and judicious manner that considers the unique circumstances of each person. This paramount concept underlies the current push to refocus our health care systems to be more patient-centered and is fundamental to the practice of high-value care, which is based on balancing the potential benefits of care with the possible risks and harms consistent with the overall needs, wants, and the best interests of individual patients. It’s clear that developing and maintaining a more personalized approach to medical practice that revolves around patient wellbeing is surprisingly not easy in our current health care landscape. However, with the progressive aging and complexity of the population combined with an ever-increasing number of diagnostic and treatment options available, this key function of the physician will become even more important in the future. And it is this approach to patient care that we must strive for if we are to meet the challenge posed by William Osler over a century ago that “The good physician treats the disease; the great physician treats the patient who has the disease.” Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP. Source
