This Is America: You Don’t Have to Do Anything You Don’t Want To

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“I just want you to know, I won’t have a colonoscopy”, my new patient said with some amount of fervor in his voice. “And I don’t want to take a lot of medications.”

I looked him straight in the eyes and said “This is America, you don’t have to do anything, and I work for you. My job is to help you know your options.”

He seemed to relax. I reflected on the words I had just uttered, yet another time – it is the way I often try to set the tone as a non-authoritarian, patient focused physician.

“You don’t have to do anything”, of course, only applies to the patient.

The doctor has to do a lot of things, like document a treatment or follow-up plan for Medicare patients with a BMI over 30, or provide computer generated patient education to a minimum percentage of patients, and achieve a certain percentage of e-prescriptions. And right about now, we are starting to see financial consequences if too many of our patients, like the man I had just met, don’t want to take the medications that can bring their blood pressures or blood sugars below certain targets.

My new patient illustrated plainly how impossible it is to be practicing both “evidence based” and “patient centered” medicine in a climate where doctors are held responsible for “outcomes” that are the result of patients exercising their free will.

Later, at home, I was reading The New England Journal of Medicine and came across a series of online posts about transforming healthcare. In one, Dr. Amy Compton-Phillips illustrates the way she feels healthcare has started to and must continue to evolve. She seems to think this nation will move “up, out” from “standardized, evidence based care” to “care driven by patient goals” very soon:

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I wonder how likely it is that payers like Medicare and for profit health insurers will loosen their grip on doctors’ day to day adherence to practices that are proven or at least strongly believed to save them money and benefit the greatest number of people, and instead allow the premiums they collect to satisfy individual, idiosyncratic patient preferences. That would reduce them to conduits for money, and strip them of their powers as arbiters and enforcers of “best practices”.

In fact, I seem to remember that’s what insurance companies were like when I was a resident more than thirty years ago. That was when doctors were supposedly authoritarian and paternalistic. In Family Medicine, that was certainly not the case – we were trained to put our patients’ values and preferences first. And back then, we didn’t get “dinged” by authoritarian, paternalistic insurance companies if our patients exercised their rights and declined to follow our advice.

I hope Dr. Compton-Phillips is right, and that healthcare in this country finds its way up and out of this oxymoronic situation that certifies clinics as “Patient Centered Medical Homes”, yet punishes them when they respect their patients’ wishes.