Came across an article in Mayo Clinic Proceedings (Makaryus, Friedman, Patients' understanding of their treatment plans and diagnosis at discharge": Aug 2005: Vol 80 No 8: pp 991-995) which
talks about how in a limited patient study (n=47); about 1/2 of them
did not know their discharge diagnosis, medication list, indications
and side effects of the medications.
Someone who has been part of the US medical system as a trainee, I
can say that it is not necessarily a wrong number (especially in a
public hospital - though I am not sure what the differences would be in
private hospitals). Sure, there are many patient factors
(understanding of disease, interest in understanding the disease,
educational level etc.), but certainly some of them are system
problems, while others physician deficits.
Few issues that come to mind:
Time (system and physician deficit)- time spent by physicians who are
running to get to see their next patient and then go to the office
(where they have a full panel of patients waiting).
communication skills - (physician deficit) - not knowing how to ensure
patient understand what comes out of the physician's mouth.
Just because they said it, doesn't mean they heard it.
Language (system issue) - difference in languages between patient and physician.
I have seen models where physicians write the discharge orders and a
RN gives the instructions, and again the same issues come to mind in
that setting as well. An additional issue may be that patients
may not "listen" to RNs as they might MDs.
Thoughts?
Biren
Came across something at Hospital Impact; where the author talks about consumer driven health care; whether it's good or bad. One of the principles in changing physician behavior is that programs where someone checks up on physicians works (ex: Influenza vaccination programs in hospitals, prescription of ACE I in hospital on discharge - where someone is assigned by the hospital to check every relevant chart to ensure compliance). But in outpatient setting, it would be hard.
Insurance companies do not have an incentive to ensure proper disease management (as pointed out to me by a colleague - who stated that most people change insurance frequently (every 2-3 years), so the benefits of one insurance company's efforts to ensure preventative medicine won't be realized that that particular insurance company - so they don't/won't do it).
So, it comes down to being responsibility of either the physician or the patient to ensure proper care. As I have said earlier, most physicians for the most part try to do their best, but anyone/everyone can have a bad day, busy day and something may get left out; or there are certainly a % of physicians who do not know the current guidelines, and do not practice based on the best available evidence. So, ultimately it HAS TO BE the responsibility of the patient to ensure they get the best care. Patients can not be passive consumers anylonger. They must become active participants. I would love to know how much time a patient spends on getting educated about their health: - diabetic learnig about complications, CAD patient after an MI learning about how to prevent the next one. Is that time more or less than the amount of time they spend on balancing their checkbook monthly!!!
Biren
As
some of you know, I am taking my (Internal Medicine) boards next month, as I
was studying HIV today, realized that here is a great model for how
active patient participation works well. The model I know is from
Chandler Clinic; 2 attendings, 2-3 nurses who keep great/close tabs on
the patients; at least from my experience, patients seem responsible, seem to know their disease - I
do not have any data about their background (education, social etc.)
but being that it is a community clinic in New Brunswick, I presume
it's low).
Still brainstorming...
Biren
I came
across a grant from RWJF today, it is for public health and health
information. This is something that could be a pilot project for
us - to test how to empower patients and families. May be the
patients don't take care of themselves, but the family may!!!
Follow the links RWJ Foundation Information Links and their pioneer program. With a good plan by us, we can apply for either.
Biren
I had looked at this article a while ago... but those who care to reference it... From American College of Chest Physicians (ACCP)'s Chest Supplement in 2000.
Wally R. Smith
Evidence for the Effectiveness of Techniques To Change Physician Behavior
Chest, Aug 2000; 118: 8 - 17.
This is the link for Chest Journal.
