“What I believe really matters” – Partnering with Patients for Best Outcomes
“What I believe really matters,” my patient said to me, and she was right. It took me a while to get it, but when I did it opened a new frame of reference on quality and safety and achieving desired outcomes. Medicine today can provide more good and yet simultaneously do more harm than ever before. Understanding this modern healthcare conundrum is essential to achieving best outcomes while avoiding harm.
Our patients come to us with ingrained beliefs and experiences that affect their attitudes toward wellness, healthcare and illness; and unless we understand these and incorporate them into our therapeutic planning we may never really achieve desired outcomes. Not only can we harm patients, but they may harm themselves.
Beliefs in the value of alternative or complimentary medicines are common and many, patients use these methods. In addition, spiritual beliefs – either encompassed within religious dogma or the broader less discrete metaphysical realms – are held closely and tightly by many patients. Our therapeutic plans need to appreciate the unique differences between patients and encompass these unique beliefs into treatment plans that are not “one-size-fits-all”. We need to support patients’ beliefs unless there are strong clinical contraindications. Most importantly, those of us trained in science and most comfortable in a universe encompassing hypotheses to be tested ad nausea need to put any arrogance we may harbor regarding the beliefs of others into the closet; and close the door tightly. The goal is meeting the patients’ needs, and to that end we should use every tool in the toolbox.
There are a few notable exceptions because “doing no harm” is also a belief system, and when patients want to do things that may be harmful or counterproductive to the prescribed therapeutic strategies we should compassionately intervene.
A few years back I was caring for a patient with thrombophilia (increased tendency to form blood clots), and this condition required lifelong anticoagulation therapy with Coumadin. Although I had given my patient a list of medications and herbs to avoid because of their ability to alter the metabolism of Coumadin, and lead to possible hemorrhaging, my patient continued to take a variety of herbal remedies, including chamomile and ginseng, because her belief was that these would be helpful for another unrelated set of symptoms. Her belief was that if she took these herbs for another reason then they would not interfere with the Coumadin she needed for thrombophilia.
Unfortunately, after what was seemingly a minor fall, my patient experienced a massive hemorrhage in her thigh resulting in a progressive compartment syndrome necessitating urgent surgical decompression and post-operative ICU coagulation monitoring.
My mistake was that I simply thought that if I gave my patient the list she would read it and comply. I failed to appreciate that I needed to have the following dialogue: “Mrs. Smith, I know you believe strongly in the value of both homeopathic and herbal therapies, and I support your belief fully. However, some herbal therapies can be very dangerous for patients taking Coumadin, and I really need you to inform me about your choices before you take anything I have not prescribed. You can suffer from severe bleeding that may seriously injure you, and neither of us would ever want to see that happen. So, please Mrs. Smith, always call me to discuss any herbal remedies you may wish to take. I will give you my very best answer, and if I do not know whether something is safe I will spend some time to look up the latest information; please, please come to me first. I have your best interests at hand and we both want you to be well and happy.”
Only by appreciating what matters most to our patients are we more likely to achieve desirable outcomes and avoid harm. Providing the best medical advice while simultaneously recognizing the value of working with patients’ belief systems to avoid harm is a solution to the modern healthcare conundrum. Beliefs matter!
Daniel Cohen is international medical director for Datix, a clinical risk management software company. He was formerly chief medical officer for the U.S. Department of Defense TRICARE Healthplan covering more than 9,000,000 beneficiaries. In that capacity, he had oversight for clinical quality and patient safety. Cohen trained in pediatrics and hematology/oncology at the Boston Medical Center (Boston University) and the Children’s Hospital and Dana Farber Cancer Institute (Harvard University). He is a senior fellow of the Royal College of Paediatrics and Child Health (UK) and a fellow of the American Academy of Pediatrics. Cohen is a member of the Editorial Advisory Board for Patient Safety & Quality Healthcare and may be contacted at dcohen@datix.co.uk. This essay first appeared as a blog post on the Datix website: www.datix.co.uk