By John Maa, MD

The uniquely complex American construct of healthcare evolved over decades. As such, the most important lesson from my career in surgery that I share with my “patients” on a daily basis is to have “patience” and not rush to overdiagnosis and premature treatment.

Therefore, as we seek to optimize access to safe and high quality healthcare, it would be wise to patiently spend several months analyzing the problems in an open, unbiased, and thoughtful manner.

We are only at the beginning of an endeavor that will require decades to complete. Before attempting to propose reforms, we need to develop a common language to communicate, and to answer simple questions such as:

• What defines quality of care?
• If access to basic healthcare is a right, then what are the attendant responsibilities and expectations for patients?
• What should be done for cases of medical futility?
• What is a reasonable waiting period to receive elective medical care?

The difficult task ahead is to perform the careful analysis to define improvements and proper solutions for (our existing emergency care) system, which serves as the foundation for healthcare delivery across our country.

We should openly acknowledge the many ways that money and profit drive not only the healthcare delivery system, but also the debate regarding healthcare reform. The millions of Americans employed in the pharmaceutical, device, and insurance industries, the physicians, nurses, allied health professionals, hospital administrators, medical malpractice attorneys, and healthcare economists, each have careers and livelihoods at stake, and are inclined to protect their own interests, often by deflecting public attention elsewhere.

We should also acknowledge that some elected officials who champion healthcare reform are motivated by the desire to either win votes for election, or to define their legacy as an architect (or stopper) of landmark healthcare legislation.

But what those elected officials often don’t mention in their speeches is the key role that patient responsibility must play in redefining the healthcare system: in combating obesity through exercise; in tobacco control; and in imparting realistic expectations. These important points don’t win votes, but they will play an important role in controlling healthcare costs.

We should remember the valuable lessons of past experience. While the introduction of Medicare as a single payer system for Americans older than age 65 did reduce administrative costs, it was simultaneously also a catalyst to an unintended overall increase in healthcare expenditures, and a rise in physician salaries.

This government-based reimbursement system disconnected direct payment from the patient to the physician, relegating it to a third party who “is not in the room” when the care is delivered. This led to an expansion of the fee-for-service industry, with an unintended incentive for physicians to perform more procedures and tests, and ushered in the period when patients began to regard healthcare as an entitlement, and to expect more in services. Ultimately, we will need to address this central disconnection between the recipient, provider, and payer of healthcare.

Many Americans are quite satisfied with the care they receive, and are concerned about changes that may compromise their access to healthcare, particularly if they perceive that a sense of urgency is being created to adopt solutions for incompletely characterized problems. The solution to such a complex situation will require a balanced perspective, and the patience to thoughtfully reflect upon critiques of proposals under consideration.

Fundamentally, we may come to realize that too much is spent on healthcare already. If so, the central task is not to search for extra sources of funding to pay for coverage for the uninsured, but to be more intelligent about how and where our healthcare dollars are spent. Ultimately, regardless of whether one is a patient, provider, supplier, or payer of healthcare, we likely can all make valuable contributions to promote greater efficiency in the American delivery system. Perhaps the key principle that will transform the existing money driven medical system is to consider healthcare as a public good. In the end, we will likely identify ways to reform our society as a whole.

John Maa, MD, is an Assistant Professor in the Department of Surgery, at the University of California, San Francisco. Dr. Maa is also the Assistant Clerkship Director for Surgical Education at the UCSF School of Medicine, and Assistant Chair of the UCSF Department of Surgery Quality Improvement Program.

The opinions expressed are those of the author, not of the Healthcare Journal of Northern California, its publisher, or its sponsors. We look forward to your comments. Dr. Maa has also written for UCSF's news publication.

It was a tough week: a flat tire on the Kompressor, four Filipino patients called you “Doc,” you apologized profusely to the wife but you are still unsure regarding what, a dog owner left it and you stepped in it, Andronico’s was out of Comte cheese, you saw 20 patients Wednesday but only remember three (including the crazy one), your 10-year-old did not turn in his homework Wednesday, your 8-year-old gave you a roundhouse kick to the left nut, the condom broke and you received a jury summons. Apparently, and to your surprise, the patient and his family don’t care about the trials and tribulations of your week. It is not apathy — what they care about most is why they are in the hospital and when they are leaving.

Maybe it’s time to re-think the way we give them that information.

In September, the Accreditation Council for Graduate Medical Education, or ACGME, held a design conference with the Picker Institute on “Patient and Family Centered Care and Graduate Medical Education.” In 2007, the ACGME established a Patient and Family Centered Care (PFCC) Advisory Group to explore its effects on the learning and patient care experience of residents and fellows. This conference was a follow-up to 2007, to introduce to a wider group in graduate medical education the concept of PFCC and its application in teaching hospitals.

Beverly Johnson, CEO of the Institute for Family-Centered Care (IFCC) in Bethesda, Maryland, reviewed the evolution of PFCC that started with the surgeon general’s office and C. Everett Koop, M.D. She described multiple paradigms like Systems-Centered Care built for the convenience of the system and providers, Patient-Focused Care where we do things to and for the patient, but not with the patient, and Family-Focused Care where we do things to and for the family while they are underneath a magnifying glass.

PFCC is differentiated from the aforementioned models by four concepts: people are treated with respect and dignity; physicians and nurses share complete and unbiased information in ways that are useful and affirming; patients and families participate to enhance control and independence; patients and families collaborate with providers in policy and program development as well as care delivery.

I admit, PFCC may seem like a close call with nonsense. If you were to apply for a PFCC patent, the U.S. Patent Office would reject your application on the grounds that the patent claims are obvious: respect and dignity, information sharing, participation, collaboration. But these concepts are some of the hardest to implement because the most germane components are relationships, not technology.

The PFCC paradigm addresses the fact that social isolation is a risk factor and patients who are most dependent on hospital care and the larger health care system (the very young, the very old, and those with chronic conditions) are most dependent on families and other support. Families can be viewed as the constant across multiple medical transitions and settings and essential to the management of chronic conditions. Johnson highlighted that the VA electronic medical system lists the “Next Of Kin,” but does not answer the question of who the family is — which could readily be a girlfriend, neighbor, college roommate, or uncle. And the concepts of cultural and linguistic competence are inextricably linked to PFCC.

Rosemary Gibson, MS, a senior program officer at the Robert Wood Johnson Foundation, described a study on family meetings at four Seattle-area hospitals. It involved 214 family members from 51 families. The conversations were audio taped and family satisfaction was measured afterwards. The average meeting was 32 minutes long, with a range of 7 to 74 minutes. The family spoke, on average, 29 percent of the time and the physician, 71 percent. What they found was that the family satisfaction with the meeting had a positive correlation with the percentage of time the family was allowed to speak, regardless of the total duration.

Juliette Schlucter, a mother of two children with cystic fibrosis at Children’s Hospital of Pennsylvania (CHOP), is a Parent Advocate and Project Consultant for Family-Centered Care at CHOP. She acknowledged the medical uncertainty of medical care but stated that mothers would know with certainty the patient’s fears, dreams and preferences. She wanted CHOP to honor the expertise that the family brings. They have formed a Family Faculty, who uses their personal narratives as a teaching platform for the residents’ curriculum.

The first group to articulate this collaboration with patients and their families wasn’t family practice, pediatrics, or internal medicine, but orthopedics. The American Academy of Orthopaedic Surgeons (AAOS) stated goals of their Patient Centered Care Campaign such that residents in all their 150 training programs take the AAOS course in Patient-Centered Communication and that 25 percent of AAOS members complete the course by 2008. Similarly, the American College of Physicians, American College of Surgeons, American Academy of Pediatrics, and American Association of Family Practice have formulated their own PFCC policies and practices.

There were efficiencies and workflow changes to any place that instituted PFCC. Letting families be present during rounds meant telling them when they occur. At the University of Cincinnati, they started PFCC in pediatrics by having the doctor, nurse and family all present in the room during rounds. They found that the rate of patient discharges before 2 p.m. improved from 40 percent to 90 percent. The pediatric residents observed that they were no longer called back after rounds by the parents to return and explain medications or appointments.

At many hospitals, PFCC is already happening even if it is not formally called “Patient and Family Centered Care.” There are doctors who round in the room with the nurse, patient and family all present. Hospitals are piloting nurse-to-nurse change of shift at the bedside with the patient’s active attention.

Seeing patients and families at ICU rounds and participating and collaborating in care may seem like an anomaly, as if they’ve entered our dojo. And perhaps they have. It may make you want to run out of the building, into the doctors’ parking lot and sprint home. But Patient and Family Centered Care is not a place or a building or a machine; it is holophrastic, like hospice — a complex of ideas expressed in a single word or phrase.

Patient and Family Centered Care, as a term, is ripe for being thrown around carelessly as a cliché, like “thinking out of the box,” “I can bench 300,” and evidence-based medicine. But it may become the new paradigm in hospital practice.

Daniel D. Shin, M.D., is an infectious diseases specialist. He is an assistant clinical professor of medicine at UC San Francisco and is in private practice in Mountain View.