Handle With Care (Part 2)


Endocrine News continues its conversation with some of the clinical practitioner members of the Endocrine Society on their views of patient-centered care. What does it mean for a practice, a patient, and the physician?

This article picks up where it left off last month with an ongoing dialogue among physicians about what constitutes patient-centered care. While it is easy to say that all one has to do to achieve this goal is to “put the patient first,” that is an ideal that is often easier said than done.

In a 2012 blog post at www.healthaffairs.org, James Rickert writes about three obstacles that could possibly impede the path to patient-centered care: reimbursement models, dependence on quantity over quality, and a reliance on generalists who don’t necessarily put patients first. Although Rickert holds up accountable care organizations as a potential solution to these obstacles, he concludes that every patient deserves “empathic, trusted doctors with whom they feel they have a personal relationship, and who are working hard for no reason other than the care of the patient at hand.”

Here are more opinions on what clinician members of the Endocrine Society think of this care model, how it affects specific diseases, as well as specific patients. All those we spoke to agree that this is a delivery method to aspire to where the patient becomes a partner in his or care.

James V. Hennessey, MD, director of Clinical Endocrinology at Beth Israel Deaconess Medical Center 

In my practice [patient-centered care] means that I assess the needs of the patients who are referred to me. Some have very straightforward problems like thyroid nodules, thyrotoxicosis, overt hypothyroidism, osteoporosis, pituitary tumors, or adrenal masses. For these individuals, I strive to provide the most efficient, effective, and supportive care to resolve the patients’ objective issues and educate the patient to the timeline and course of evaluation and therapy. Once a diagnosis has been established, I try to provide the most evidence-based solutions available to assure that the patient has received the most mainstream and proven interventions.

Patient-centered also means that I will lay out a plan to provide directed and supportive care until the problem is resolved. For example, a patient with a 3-cm hypoechoic thyroid nodule will receive a FNA, feedback on the results, referral to a surgeon as required, and post-operative support for either a malignant or benign diagnosis. Providing longitudinal care may eventually result in yearly follow-ups to assess the effectiveness of LT4 treatment, dose adjustments, or further education on appropriate ingestion procedures and an opportunity to provide further care and screening as the patient ages such as reaching DXA screening thresholds.

For some patients, patient-centered care is best delivered by saying no. For example, an 86-year-old with a TSH of 4.6 and normal FT4 should be told no, there is not enough evidence that LT4 treatment will enhance their quality of life. Further evaluation, such as repeating the TSH and perhaps measuring a TPO-ab titer would be the most appropriate next step. Over time, the patient may be returned to the primary care physician (likely NOT on LT4) when subsequent TSH values +/- TPO are all normal.

Another scenario would include the patient dissatisfied with his or her quality of life when euthyroid or euthyroid on LT4 mono-therapy. Here, there is frequently some Internet-driven search for a “provider” to supply Liothyronine.

As a physician, I feel it is patient-centered care to search out the other explanations for less than optimal quality of life issues such as other chronic medical conditions like obesity, obstructive sleep apnea, other serious issues like congestive heart failure or chronic obstructive pulmonary disease, and the multiple medications with side effects that match the symptoms far better than hypothyroidism. Here I believe that patient-centered care is to assess what is best for the patient, whether to supply an easy prescription for what frequently turns out to be a placebo effect or to actually help discover the real reason for the patient’s problems. Clearly, some might consider this approach to be paternalistic while others would recognize it as professionally appropriate.

Barbara Onumah, MD, of Anne Arundel Medical Group in Annapolis, Maryland

Patient-centered care to me means providing care that is respectful, considerate, and places emphasis on what is important to the patient, instead of what the provider deems important.

In a patient-centered environment, empathy, a patient’s values, and preferences, combined with standardized evidence-based principles, guides clinical decisions.

In my practice, I think of patients as “partners.” The care is individualized and no two persons are treated alike even if they have similar medical conditions. Because patients are partners, they get to play an active role in the decisions surrounding their treatment, including medication choices where appropriate.

Elaine Pelley, MD, director of Preclinical Medical Education at the University of Wisconsin School of Medicine and Public Health

Patient-centeredness is essentially a guiding principle in patient care, rather than any specific action. It can manifest at the individual patient level, for example, in shared decision making during a visit or by allowing a patient’s choice in methods of communication (in person, phone, or electronic messaging). But it can also occur at a systems level, such as having evening or weekend clinic hours or providing outreach clinics in remote areas.

An important facet of patient-centered care is that once the patient, not the physician, is at the center, that leaves more room for other members of the healthcare team to contribute to the care of the patient. In my practice, this model has allowed me to focus on new patient evaluations and more complex cases while sharing in the follow-up care of most patients with a physician assistant. This has increased our ability to serve more new patients while simultaneously providing our current patients with two providers that understand and are engaged in their care.

Alan D. Rogol, professor of pediatrics, University of Virginia, Charlottesville

I am a pediatrician who evaluates most patients through the prism of the family. So, patient-centered care means evaluating and treating patients in the context of the family. The condition (whatever it is) requires several layers of “thought”: what does it mean to the child — for the very young this is not so much of a problem given that the parent does the talking and acting. But as the child matures one must put her/him into the equation and understanding at the various developmental ages is a skill that requires honing. I certainly was much better after four decades of “practice” than I was at the beginning.

As the child matures into an adolescent one must work with an equation that communicates more with the actual patient but at the same time working through the parents — both parts of the equation do not necessarily get equal weighting and the adolescent’s privacy, etc., becomes more important. Not so infrequently the agendas of the parent/adolescent dyad are disparate and that tries the skill of the clinician.

Perhaps the best examples have to do with sexuality in the adolescent which is altered remarkably with increasing maturation and one approaches the adolescent and the parents in quite different manners.

R. Michael Tuttle, MD, Memorial Sloan Kettering Cancer Center

To my mind, patient-centered care should be the goal of all patient-clinician interactions. It is a reminder that every medical decision (management decisions, follow-up options, treatment options) should be first and foremost based on what is best for that individual patient. And even more importantly, “what is best” for that patient may or may not be what I personally would do in that same situation. But by balancing my opinions and expertise with the respect for the patient’s preferences, we can jointly develop a management strategy that optimally addresses the key issues important for that patient. Being patient-centered also is a reminder that there are multiple other people/institutions/entities interacting with the patient (family, friends, primary care clinicians, community, healthcare organizations, insurance companies) and that when developing a “best plan” for that patient, these other forces that are interacting with the patient also need to be considered.

Leonard Wartofsky, MD, MACP, professor of medicine, Georgetown University School of Medicine; editor-in-chief, Endocrine Reviews

To me, patient-centered care is the opposite of physician-centered care wherein the doctor, as an authoritarian, dictates what he or she thinks is appropriate and expects the patient to accept and follow the recommendations without question. Thus, such care is not particularly respectful of the patient’s specific needs and cultural values. Patient-centered care aims to acknowledge patient and family preferences, provide support and counsel, and develop treatment plans in concert with social needs of the patient.

  • Derek Bagley is the senior editor of Endocrine News. He wrote about diabetes and the aging patient in the December 2016 issue.