by Terri Bernacchi, PharmD, MBA, Health Advisory Professionals
Sometimes people are most comfortable when someone else makes the difficult decisions in their life (and then takes the associated blame for when things turn out poorly). Others (like me) need to know all the options, odds and consequences for each, receiving counsel from trusted sources, and then making an educated decision. This is true for life decisions and for medical decisions, alike. In essence, it is for all decisions, great or small, regardless if there are just two alternative options or many.
One must weigh the options, rate the implications, and make a decision. And making no decision is still making a decision.
The link listed below contains an excellent posting about how complex medical decisions made on behalf of patients by physicians are often (when reviewed with the perfect clarity of hindsight) found to have been “unnecessary”. Key examples offered include such daily concerns as when to order a CT scan or implant a defibrillator, but these kinds of decisions are made all the time----some with little cost and consequence, some with profound cost and consequence.
Certainly, there is a theory that by applying more stringent governmental regulations on clinicians, only those patients that fit the narrow criteria for a treatment will receive it, saving vast amounts of otherwise wasted resources. As most of us who have “been there” know, it’s not quite that simple.
A recent JAMA article concluded for the 111 internal defibrillator patients reviewed,”Among patients with ICD implants in this registry, 22.5% did not meet evidence-based criteria for implantation.”
Shannon Brownlee, the author of this linked post about “Sharing Decision Making” notes one of the most challenging conundrums, using the defibrillator example, of modern medicine in the United States: physicians and patients do not make decisions in the same ways; and they don’t necessarily realize the gap between what each considers most important. http://health.newamerica.net/blogposts/2011/sharing_medical_decisions-42668#
She cites rightfully, that the implantation of defibrillators is a lucrative procedure for physicians and hospitals alike. She also makes a solid case that the decision to implant one of these devices is not always a black-and-white circumstance. Evidence-based clinical guidelines are in place to help surgeons select which patients are most likely to derive the greatest benefit. But doctors are routinely faced with patients who fall into the gray----who don’t exactly fit narrow criteria, but might receive some benefit from the device anyway and so they receive it. She also makes that case that some physicians may be unaware of the guidelines or evidence, thus not putting them into practice.
The line of distinction that I would like to draw is this one: the physician does not generate the same fees from NOT doing a procedure as he or she receives from DOING one. Thus, there is a frequently financial interest that weighs----whether recognized or not---as a potential medical conflict of interest between the objective needs of the patient (in the eyes of his provider) and that provider’s financial arrangements related to the options under consideration.
Ms. Brownlee notes that “...when patients are given a chance to be fully informed, and to share the decision about an elective treatment with their doctors, they often make choices that are very different from those their physicians would have made for them.”
In order to actively advise (as in “Shared Decision Making”) a patient on the medical alternatives without that bias weighing in by fact or appearance, a clinician must be able to divorce him or herself from the financial consequences of the “next steps” and truly sit on the same side of the table as the patient. This may not be possible in today’s medical construct and may be best remedied by a new kind of practitioner------one with experience and knowledge about how to objectively log and rank the medical alternatives, one with great listening and empathy built into their personality, but one who is not conflicted by the active practice of medicine and its payment schema. This clinician can guide and help the patient to a new kind of informed decision making----one which may reduce pain and suffering but also yield financial savings for the patient and the system alike.
Terri currently works for a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders in health care as a Senior Principal in Managed Markets. The thoughts put forth on these postings are not necessarily reflective of the views of her employer nor other Health Thought Leader colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.
[1] JAMA. 2011;305(1):43-49.
No comments:
Post a Comment