Keeping the Patient in the Equation — Humanism and Health Care ReformPamela Hartzband, M.D., and Jerome Groopman, M.D. Over the past decade, two major movements have emerged in medicine, both intended to improve patient care. The medical humanism movement seeks to understand the patient as a person, focusing on individual values, goals, and preferences with respect to clinical decisions. The second movement is evidence-based practice, which aims to put medicine on a firm scientific footing; experts evaluate the best available data and develop clinical guidelines designed to standardize procedures and therapies. These two movements will now play out in the context of national health care reform, the goals of which are universal coverage and cost containment. Until now, the two trends have largely progressed in parallel, with mutual acknowledgment of the other’s merits. But now, when it is most important for them to coalesce, they are poised to collide.
The World Health Organization (WHO), in its June 2000 assessment of medical care systems around the world, used “responsiveness” as one of its major criteria.1 This concept encompasses the core principles of medical humanism — specifically, dignity for individuals and families and the autonomy for them to make decisions about their own health. In the United States, medical education has increasingly emphasized the importance of understanding patients’ individual concerns and values. To this end, medical schools and residency programs now routinely teach and assess cultural competence, for example, and a growing literature highlights the diversity of patients’ experiences and ways for doctors to better individualize their care.
This approach represents a sharp shift from the traditional paternalistic role in which doctors simply told the patient what to do without factoring in his or her wishes. The new model incorporates “shared decision making,” in which the physician attempts to provide the patient and family with the full range of information about the clinical problem so that they can assess potential risks and benefits and make an informed decision about how to proceed. Part of the ethical basis of shared decision making is medical professionalism — the notion that doctors should always align their interests with those of the ill person and be free of any self-serving motivation so that patients can trust their physician’s advice.
At the same time, the application of scientific evidence rather than anecdote to clinical practice has extended to virtually every area of medicine. Principles of evidence-based medicine have become central to medical education and the development of clinical acumen. Patient safety has been markedly improved through the stringent implementation of infection-control measures and “cockpit rules,” with validated checklists, for example, being used in operating rooms and intensive care units to prevent avoidable errors. Expert panels convened by professional societies and other organizations have promulgated guidelines for the prevention and treatment of various illnesses. These guidelines are meant not only to make care more scientific, but also to even out regional variations in practice and potentially to cut costs.
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http://healthcarereform.nejm.org/?p=1350?query=TOC#printpreviewSource InformationFrom Beth Israel Deaconess Medical Center and Harvard Medical School (P.H., J.G.) — both in Boston.
© 2009 Massachusetts Medical Society
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