Sunday, March 1, 2015

Of Thermopylae, The Simpsons and Patient Centered Medicine

The Battle of Thermopylae or
an image of modern patient care?
What can the Battle of Thermopylae and The Simpsons teach us about patient centered medicine?

The Disease Management Care Blog says read on.

At one testosterone-laden point in the six-pack riddled fantasy movie "300," the Spartan narrator admires how some non-Spartan warriors made a "wondrous mess of things" at the Battle of Thermopylae.  It was professional warriors accommodating the pitchfork wielding non-professional farmers in the drive to victory.

And so it is with "patient centered medicine." When it read the New England Journal Perspective by Charles Bardes titled Defining "Patient Centered Medicine," the DMCB was reminded of a coming mess in health care.  That includes the doctor-patient relationship, payment and quality measurement, all of which promise to be scrambled by a decidedly non-professional, imprecise and radical notion: consumers are going to have a big role in what drives value in health care.

While DMCB readers are already familiar with the rhetoric of consumerism, empowerment and shared decision making, Dr. Bardes reminds us that full adoption of PCM will go far deeper. PCM is based in a "biopsychosocial model" that trumps illness over disease and caring over curing. It's rooted in 1960's style psychotherapy that involves a highly tailored, shared and special therapist-client relationship where the journey was no less important than the destination. Graft that onto modern notions of consumerism and medical "value" goes from being scientific, precise, quantitative and measurable to being subjective, shifting, qualitative and immeasurable.

This is important because it redefines the one-sided "special knowledge" that defines the doctor-patient relationship,threatens the business-as-usual payment methods and calls into question the use of measures like HEDIS and Medicare's HospitalCompare.

This may be silly, but think about donut munching Homer Simpson and what this could mean for primary care.  While one would expect Homer to get a prescription to control his diabetes, generate a monthly management fee for his patient centered medical home and have an A1c (that would probably undermine his PCP's quality scores), that goes all away in PCM. What we have instead is empowered Homer ultimately deciding if he really wants to take any pills, payment that is based on his subjective satisfaction and quality measures that record whether Homer was allowed to make informed choice among several treatment options. Whether Marge gets a mammogram is not important; it's whether Marge actively choses to get a mammogram or choses not to.

To Sparta's credit and Hollywood fiction aside, the historical record shows Spartan King Leonides et al welcomed the help of their amateur Greek brethren in stopping the Persian invasion. So, here's a question for the the DMCB's professionals colleagues running the health care system: are we prepared to accept the participation of Homer and Marge in reshaping a dysfunctional health care system?  If the answer is yes, where in the battle can we use them and how much "mess" are we willing to put up with?

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