While discussing over-crowding and ‘safe, quality care’, a retired nurse manager said, “It’s all about doing what’s best for the patients.” She told me, “People try to call it patient safety, but it’s just covering your butt.”
Motivations to help patients versus protect ourselves start to compete when Medicare runs short of money.
With enough resources, providers can protect themselves and focus on patient benefit. When resources get scarce, providers often have to choose between patient benefit and self-protection.
For example, no one gets criticized for providing ‘really great care’ inside an emergency department or on an inpatient ward. They’re patient-centred. But providers can spend as much time as they want with patients only if they make other patients wait for hours (days!) in the ED waiting room or admitted in ED hallways. Providers can champion ideal care settings – proper rooms, great infection control – only by forcing other patients to endure no bed, no quiet, and no infection control in an ED hallway or waiting room.
No one will fault a nurse or physician for working ‘really hard’ and doing a ‘really good job’ with his patients. Discharge excellence, thorough education, exploration of psychosocial factors; no one can criticize a provider for ‘working hard’ to be patient-centred.
Are We Patient-Centred?
Are we really working hard for patients or are we just covering our butts? Are we avoiding the risk of having to see a new patient in a less-than-ideal setting? Are we aiming for ‘faultless’ care for our patient because we want what’s best for patients, or because we want what’s best for us?
But we’re already at the 25th percentile for length of stay! What more can we do?
Even if care gets trimmed down to the shortest possible, leaving patients to languish in hallways and waiting rooms goes against everything healthcare believes in. Both emergency departments and inpatient services do the same thing. EDs leave patients in waiting rooms; wards leave patients in the ED.
Our system does not have resources to allow providers to give ideal care all the time. Even if you don’t have enough to give patients your best, you can still give them something; letting them languish in the waiting room or ED is egregious.
Healthcare providers can describe their concerns in terms of quality, professionalism or patient benefit without being patient-centred. When we make these comments in the face of unconscionable waits and suffering elsewhere – suffering that we could do something to alleviate – we are just “covering our butt.”
What do you think? What role does self-protection play in our refusal to get patients out of the waiting room or up to the wards?
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(The photo comes from an MSF page about Patient-Centred care for TB patients in Armenia. Check it out, too.)
Which is that scarce resources drive a wedge between the low-maslow-stage of providers and patients. So whereas with abundant resources, there’s no conflict, with scarce resources, we’re going to protect ourselves at the patients’ expense. Different providers do this to different extents, but the system is made to reward such behaviour while our consciences try to prevent it, setting up internal conflicts in providers between what we went into the profession to do, and keeping our licences and livelihoods intact.
Brilliant comment, Marko!
Well said. It takes strong, aspirational leadership to help staff look beyond self-protection and seriously consider what patients need.
Thanks for commenting!
Shawn
Shawn….well written and thoughtful.
Protecting ones self is what we all do in any business. Forgive my over simplification but while each consult should be alloted adequate time as agreed to by both doc and patient there simply are not enough of YOU! I appreciate many patients would like to camp in your office, so when I say reasonable ….more than 5-10 minutes which is what most docs spend. Pay per patient and the number each doc is scheduling causes limited time to assess and assuage patient need to fully explain their symptoms and concerns. Physicians would benefit from courses that highlight “listen skills”…. Many US based HMO”s make such seminars mandatory now.
Govt must show true leadership and allow private practice. The dreaded hybrid model.
I for one …greatly appreciate your blog as it encourages constructive dialogue from fellow physicians and people like me…a patient.
Cheers
Thanks so much for commenting, Don!
I agree that your suggestion to renovate the whole system would radically change how we view patients. I hope we keep that aspect of discussion going; keep looking at other successful models in Europe; refocus discussion on patients instead of policy and government.
As always, I really appreciate you taking the time to read and reply.
Looking forward to your next comments…
Shawn
Don Taylor is, I believe, making two suggestions:
1. The value of physician time to patients who increase if doctors did their jobs better by gaining more skills (he mentions listening skills) and
2. The government should realise that 5-10 minutes is not enough per patient and should pay doctors differently, and more, so we can spend more time with each patient.
No one can argue with #1.
#2 is what the whole post is about. OF COURSE doctors want to be paid more so we can work a little slower and take it a bit easier without taking a financial hit. OF COURSE patients want their doctors to be less rushed. The problem is, who pays?
If I had to pay the doctor $50 to spend 10 min with me (the $50 pays for his office, secretary, pension, holiday time, disability, malpractice insurance etc.–it’s not what he takes home, but it IS what I would pay as a patient), would I want to pay $100 for him to spend 20 min with me? Public health payments don’t give doctors or patients this option because soon enough, every visit would be an hour and cost $300 and no one would get an appointment for months. But should patients be allowed to pay for more doctor time if they want it?
Similarly, nurses are always arguing for richer ratios. Acute care is often nursed at a 1:4 or 1:5 ratio (one nurse, four patients) while the intensive care unit is 1:1. If a ward patient would prefer to have a nurse’s full attention, in a public system, should he be allowed to fund it? Nursing is 75%-80% of the cost of running any hospital, so it’s clear that the public system could not increase nursing by any substantial extent without a major tax increase that would be objected to by taxpayers.
So…in a financially constrained system, what is patient-centred care: is it
1. providing the best care I can to ALL the people in my waiting room (or on my waiting list) keeping in mind that there are compromises to be made so everyone gets some; or
2. providing the best care to the people who get to see me, and no care to those on whose charts my name does not appear, because they never see me, and therefore I can’t be blamed for not caring for them (well, or at all?)
If you have a bottle of wine to share among seven friends (a bottle is five 5-oz glasses), do you pour a glass for the first five and leave the last two glasses empty, or do you share the 25 oz of wine equally among the 7 glasses? The first way, two friends will say you never poured them any wine, and you can say you did not have any wine to pour, but you can’t be blamed for not pouring wine you did not have, can you? The second way, everyone complains they did not get enough wine. Do you want to field complaints about inadequate pours from all seven people?
Excellent! Another brilliant comment, Marko.
Of course, people would argue that you’ve presented care as a continuous variable (a concept I agree with), but they might say it is discrete. While antibiotic doses are usually discrete (we have to give a certain amount to expect any effect), most things in medicine still work when they get stretched more thinly than most would prefer.
Thanks, again, for taking the time to respond!
Shawn