New Threat: “Patient-Dictated” Care

While we’ve been worrying about nuclear war and rising global fascism, a post on KevinMD last week reminded us of a persistent and no less real danger: patients who ask for shit. The blog’s author draws a line between “patient-centered care” and “patient-dictated care”, the latter of which entails the physician sighing mightily yet rolling over at any patient request. What choice does he have, really? He’s just trying to keep the lights on in this crazy world.

The example given is antibiotic abuse, that old workhorse – just as scary and describable as it was in that 60 Minutes episode back in 1998. Can You Believe this Asshole Wants Antibiotics for a Cold?! has been kicking around at least since I was in high school, and despite its wear, it won’t die as the catchall justification for why physicians must remain the keepers of the knowledge. They are the rare, anointed ones, elevated by the combination of intellectual superiority and moral purity; they alone understand the dangers of antibiotic resistance.

According to the KevinMD blog, the only antidote to Pubmed and the big, confusing internet is a more trusting doctor-patient relationship, which the author describes as impossible given the increasing administrative burden placed on physicians. Well, shucks, if my doctor took more time to push me toward a procedure, diagnostic or drug that made him a little cash, wouldn’t that just fix healthcare? Doctors are more than willing to spend 40 minutes talking to you when they want you to do something, so why the resentment toward patients saving all that time by making a suggestion themselves? Do those checks not cash?

The article minimizes one point: we have fee-for-service healthcare where physicians are incentivized to perform procedures and order diagnostics. Patients are aware of this; it’s that pesky 60 Minutes again. Of course I have preferences, and the physician has preferences too. That never gets acknowledged without qualification; patient desires are whims and rooted in more, more, more, at any cost; the physician is the moderate one who makes decisions based on value and evidence alone.

Right. If a therapy or diagnostic is suggested to me, most of the time I’m about 90% sure that it’s for the financial benefit of the practice; if it weren’t, the physician wouldn’t take the time to pitch it. Where the article is right is that administrative burden is real, and this does affect face-to-face time with patients – so much so that a doctor asking me about my weekend or otherwise wasting time makes me suspicious, and I know it’s nothing more than a prelude to some ask. I say no to everything, because I enjoy that little fuck-you to the system. In an environment where I am largely powerless (and despite these accusations of the rise of “patient-directed care”, I am), No is the only chance I get to acknowledge those biases. This is the rebellion I’d love to see, where patients start questioning all the tests, all the charges, all the excess; that could drive true value-based care, because physicians would have to start treating for utility, for outcomes. And doctors think their problem is the patients who say Yes?

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