But Is It Really Patient-Centered?

I came across two posts today which, in an abstract sort of way, brought up in my mind how we decide what is best for the patient.

First, Dr. Suburban [whose new blog Suburban Emergency is starting off with some interesting provocations] describes a procedure that would have been done in many (but most definitely not all) ER's in the country. A conflict erupted over different stakeholders' definition of what is best for the patient, while nurses are playing Sudoku. The arguments are valid on all sides, as presented by Dr. Suburban, but think about how resources are distributed between hospitals and within this hospital.

The WSJ Health Blog raises some interesting questions about OTC meds, when The Lancet appears to endorse OTC birth-control. This too is advocated on its net public health merits and the point that anyone who wants contraception should have it. Of course, the costs associated with an unwanted pregnancy are much higher than any costs of adverse health events; that should be a given statement as obvious as "penicillin saves lives of pneumonia patients" would have been in 1945. But it is political.

Patient-centered medicine is a term I first heard from Moira Stewart and her colleagues in London, Ontario. The term has been used for advocacy, but is often thrown around as an excuse for organizing around the needs of one group or another within a hospital or across a health system.

It is in a physician's best interest to use the ER to reduce a wrist fracture, but safety prerogatives require an experienced support staff. It is in the patient's interest to have a minor procedure in the same part of the hospital she entered. There are risks to handoffs and risks to doing conscious sedation in the ER. Everyone wants to do what's best for themselves in this case, but uses the patient as their rationale. Did anyone ask the patient?

As for oral contraceptives, there are risks of increases cervical cancer if you believed that giving all women the pill will lead to rampant unprotected intercourse. Well, your daughter maybe... [Can you imagine how that statement would play it in Southern Baptist country??? I am being naughty aren't I?] I would also have to raise the issue of breast cancer, a miniscule but emotionally potent risk. Probably, the greatest population level risk would be an increase in thrombotic events. The net effect on a social-economic-health basis may very well be positive because of the reduction in unwanted pregnancy, not even considering ovarian cancer risk.

I wonder if we should ask the patient, if we were truly being patient-centered.?

Sometimes, no matter what, there is sufficient evidence to acknowledge that the correct patient-centered response is to say no. But before we stand on our soap-boxes claiming we are centered on the patients' interests, we should make sure we are not just trying to make our own lives easier.