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The '10 commandments' for patient-centered care

The '10 commandments' for patient-centered care
REUTERS/Jim Young
The National Academies of Sciences, Engineering and Medicine has estimated that unnecessary medical care accounts for 30 percent of health-care spending in the U.S.

Five advocates of the less-is-more approach to medicine recently published their “ten commandments” for patient-centered treatment.

Although aimed at physicians, the rest of us can learn a thing or two by reading these edicts — and encouraging our personal health-care providers to follow them.

The article with the “commandments” appears in the British Journal of General Practice. Its lead author is Dr. Richard Lehman, a British primary care physician and a senior adviser for Cochrane UK.

Although written with humor, the message behind each of the “commandments” is serious — and urgent. As the surgeon, public health researcher and best-selling author Dr. Atul Gawande detailed in an article for the New Yorker earlier this year, “an avalanche of unnecessary medical care is harming patients physically and financially” in the United States.

Indeed, the National Academy of Medicine (formerly the Institute of Medicine) has estimated that unnecessary medical care (along with excessive administrative costs and fraud) accounts for 30 percent of health-care spending in the U.S. — or about $750 billion each year. 

Here is a sampling (with British spellings) of the patient-centered “commandments” decreed by Lehman and his colleagues: 

Thou shalt, if all else fails or if the evidence is lacking, happily consider watchful waiting as an appropriate course of action

… Many consultations consist of a complex dialogue of exploration, attempted understanding, and partial uncertainty. Unless there is a clear diagnosis, it is usually better to keep the offer open of another consultation rather than issue a prescription.

Other situations where it is often better not to prescribe include acute self-limiting illnesses where symptomatic treatments are available over the counter (OTC). This also applies to some more chronic conditions such as irritable bowel syndrome and chronic back pain, which characteristically fluctuate and for which prescription-only treatments are usually no more effective than cheap OTC alternatives.

The temptation to prescribe rather than offer a timely reassessment should always be resisted.

Thou shalt honour balanced sources of knowledge, but thou shalt keep thyself from all who may seek to deceive thee.

There is no single reliable, unbiased, and continuously updated source of knowledge about effective treatments that can be shared by patients and health professionals. The closest approximation is Wikipedia, which is also the most widely used global resource, although it lacks the support and infrastructure to be comprehensive in its coverage and updating. …

Clinicians are also targeted for direct and indirect marketing by the pharmaceutical and devices industry to persuade them that new interventions are more effective than old. This is typically not the case, and they are almost always more expensive. Indirect promotion to the public occurs widely via the news media and sometimes through patient organisations if they accept funding from industry. Shared decision making with patients should rest on clear knowledge of harms and benefits, derived from objective analysis and comparison between the best existing alternatives.

All industry-sponsored sources of information should be avoided.

Thou shalt not bow down to treatment targets designed by committees, for these are but graven images.

Traditionally, elevations of single risk factors such as blood pressure or lipid levels have been labelled hypertension or hyperlipidaemia, and individuals (typically without symptoms) have been urged to take drugs to reduce them to a certain level. The very large [number-needed-to-treat] for such treatment is often not known by clinicians and seldom discussed with recipients, who now acquire a disease label and become patients, followed up at regular intervals for the rest of their lives.

This traditional model has become embedded in many guidelines and in the (UK’s) Quality and Outcomes Framework. Clinicians are paid for the achievement of a surrogate outcome such as systolic blood pressure, total cholesterol, or glycated haemoglobinA. This can act as a disincentive to the essential process of dialogue and shared decision making, which always needs to take precedence over the achievement of externally imposed targets.

Thou shalt seek to use as few drugs as possible.

Before printing off a prescription, consider whether a non-drug intervention might be as, or more, effective. Do not use drugs as a shortcut because alternatives might take more time to explain or be harder to access.

As a general rule when prescribing long-term drugs, it is best to use a single agent and use the lowest dose to start with. This usually provides the best balance between benefit and adverse effects. For example, in heart failure, the lowest doses of an angiotensin-converting enzyme [ACE] inhibitor have nearly the same mortality benefit as the highest doses, with a much lower risk of [low blood pressure, potassium deficiency, or fainting]. If you do decide to [raise the dosage], discuss the marginal benefit in full with your patient.

It is sometimes useful to use a combination of low-dose agents, for example, to reduce blood pressure. But be aware of potential harms and adverse interactions. Before you increase a dose or add another agent, make sure that you have given your initial treatment an adequate trial and that your patient is really taking it.

You can read all 10 "commandments" at the British Journal of General Practice’s website.

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