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We Need Limits to Patient-Centeredness — the Nosebleed

September 29, 2015
By

A colleague recently told me of a patient encounter he had in an emergency room. When he picked up the chart, it described the patient as a 62-year-old woman complaining of epistaxis, or a nosebleed.

He walked into the room and saw a perfectly well appearing 62-year-old woman. There was no blood on her clothes and none on her face. Her nose was not bleeding. When he asked her what could he do for her, she said that she had been out with friends and then started having the nosebleed in a restaurant. She excused herself to the restroom the way she had done in the past. Her nose bled for about 20 minutes total. This had happened a few times in the last year.

The doctor saw a little bit of old dried blood inside her nose cavity. There were no worrisome lesions and no active bleeding. There were no other signs of a bleeding disorder.

As he started to give his usual reassuring speech that she was out of danger, she made it clear that she wanted the emergency physician to call an ear, nose, and throat doctor. Never mind that she already had an appointment scheduled about six weeks later at an ENT clinic. This encounter happened at about midnight on a Saturday night. Further attempts to reassure her were unsuccessful. The emergency physician asked her more questions trying to figure out why in the world she wanted this doctor immediately called and what she expected to happen.

She explained that she takes care of her daughter’s two children, ages one and three years old. She wanted the nose doctor to take her back to the operating room, knock her out, and fix her nose so that it never bled again. The emergency doctor explained once again that there was no emergency and that no nose doctor would come into a hospital at midnight on a Saturday to fix a non-emergent problem. I’m quite sure that when she got her patient satisfaction survey a few days later she gave this experience a bad review.

The people who push patient centeredness as the primary goal for healthcare reform have many valid concerns, but this case illustrates that patients often make unreasonable demands on the system, and should be told no.

Contrast this story to my experience following a general practitioner in England, where a 92-year old woman with abdominal pain waited all night long to see her GP for a home visit the next afternoon. This was pain she described as severe a childbirth.

This consumeristic patient-centered movement talks little about the downstream effects of an entire system contorting to attempt to please one customer. A healthier healthcare system strikes a balance between the needs of an individual patient and the needs of the system to work well for all. I observed in England and Scotland a population of people who were willing to make individual sacrifices so that the system worked fairly for everyone.

I don’t see any of the PCMH models or ACO models asking patients to change their expectations or behaviors, which is why they are ultimately destined to disappoint.

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