The Cost of Bad Medicine

We are currently in a time that third party payers and government agencies are looking for ways to reduce the cost of health services. One way to do that is to attack providers and state that "a lack of quality care is the cause for increased costs."  There was great fanfare in 1995 when “To Err is Human” was published. Pundits pointed to the fact that somewhere between 48,000 and 95,000 people unnecessarily die each year in health services organizations due to provider negligence. So, Congress and the President acted.In response to this crisis, the Agency for Healthcare Research and Quality (AHRQ) developed and fielded TeamSTEPPS and has since created hundreds, if not thousands, of TeamSTEPPS Master Trainers.  Health services professionals recognized a problem and addressed it. Right?

The Cost of Non-Adherence

On the other side of the equation, however, are the people we serve. Thousands of articles and reports on patient non-compliance are available for all to read, but very little progress has been made because patient still do not follow their provider’s plan of care. Numerous new programs have been described in dozens of journals as barely making a dent in increasing compliance and yet there has not been the same focus coming out of the government.  Still, significantly more people are dying from not following their provider's plan of care.

Thousands of articles have been written stating that the word "compliance" appeared to be too harsh and patients were "non-compliant" because they were left out of the decision making process. "Adherence" they cried was a kinder, gentler term and so the word was changed. Clearly, and not to my surprise, the new and improved label has made no difference in the long term improvement of patient "compliance."

Pinpoint the Problem First

I am reminded of the chicken farmer whose chickens had become ill. Without hesitating, he went to the local guru and made his case. The guru responded asking, "What are you feeding your chickens?" The farmer replied "cracked corn" and the guru recommended adding white wheat and barley. The farmer, satisfied with the recommendation went home and changed the food. Before long his chickens continued to become ill and more died. He returned to the guru and once again stated that his chickens were dying. "How do you give them water?" asked the guru. "I used galvanized troughs," replied the farmer. Quickly the guru stated, "Copper. You must use copper troughs," Once again the farmer returned to his farm and changed out the troughs to copper. After several more days more chickens had become ill and even more were dying. Completely beside himself, the farmer rushed back to the guru. "Oh guru, I have done what you asked and even more of my chickens are sick and dying." "How do you have them living?" The guru asked. "In coops," responded the farmer. "That is the problem. You need more his coops." After a few more days, he noticed that all of his chickens had died. Completely frustrated he returned to guru. "All of my chickens have died," he cried to the guru. "That is too bad," responded the guru. "I had so many more solutions for you."

Change the Name and You will See a Difference

Non-compliance has been around from the earliest days of medical practice. "Adherence, change the name to adherence and things will get better" the gurus cried out. They have not changed, we said. "Concordance, change the label to concordance and patient's will follow their plan of care..." but they have not. "Empower them. Give patients autonomy in their decisions and adherence will improve." Non-compliance and non-adherence, along with their British cousin 'non-concordance,' still hovers at 50%. Perhaps it is time that we step away from theories designed to improve the quality of processes and move towards the science of behavior to change behavior.

Empower the Patient and You Will See a Difference

Thousands of journal articles and programs focus on “Empowering the Patient.”  It is a term that has gathered momentum as a way of having the patient participate in their care decisions. Empowerment is defined as “…to enable or give authority to someone.” It has further been described in the following paragraph.

“The empowerment approach involves facilitating and supporting patients to reflect on their experience of living with diabetes. Self-reflection occurring in a relationship for laying the foundation for self-directed positive change in behavior, emotions, and/or attitudes. Such reflection often leads to their enhanced awareness and understanding of the consequences of their self-management decisions.”[i]

Pick the word or words that describe the behaviors that you want your patient to accomplish as a result of empowering him or her. I highlighted a number of words in the definition that may seem to reflect behavior. None of them do. The cognitive components are not without meaning or merit. The real question is what did you empower your patient to do?

You cannot give that which is not yours to give

You can only reinforce the behaviors necessary to achieve better health. People seek health care services based on the consequences of their particular medical problem. No providers empowered the person to make that decision. An illness reached a point that something needed to be done. Self-empowerment was in the person's decision to seek care in the first place. Once that decision was made, we can identify and reinforce the behaviors necessary to develop new habits in support of the plan of care. None of the underlined words under empowerment is a behavior. Desired behaviors must be identified. Reinforcers that increase the likelihood of target behaviors must also be identified and used frequently. Reinforcers change behavior, not empowerment.

All of My Patients Are Adherent

For providers who may see 32 patient visits a day, it is highly likely that 16 or less of them will follow your plan of care. For the "worried-well," that may not be much of a problem. For your more challenging "at-risk" patients, the best plan of care will still reflect on your practice's lack of P for P, if it is not followed by the patient. You might see these patients for a total of 4 hours this year of the 8,760 hours we each have. After they leave your office, they will spend 1,960 hours with their friends at work. They'll spend hours on the internet looking at their disease and recommended treatments and 3,836 hours with family and friends. Your time with them represents 0.0005% of their year. That is not a lot of empowerment time.

In our next discussion, we will look at an evidence based way to identify your at-risk patients for behavioral intervention.

[i] Daniels, A. Bringing Out the Best in People, McGraw-Hill, New York, 2000.

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