Map of life expectancy at birth from Global Education Project.

Tuesday, February 09, 2010

Getting on the same page

One issue I've been interested in concerning physicians and patients is whether their priorities are aligned. For example, the doctor might be most concerned about a patient's blood pressure or blood sugar, whereas the patient is more worried about skin tags or spider veins, or joint pain. If the patient finds the doctor isn't taking her concerns seriously, she may lose trust and be less inclined to follow the doctor's advice about taking medications for the conditions the doctor feels are important. On the other hand, those problems might in fact be very important to the patient and have a big effect on his quality of life. Just because the doctor doesn't see them as life-threatening, or perhaps as not affecting his pay-for-performance contract, doesn't mean he doesn't have an obligation to the patient to take them seriously.

Donna Zulman et al, in the new Journal of General Internal Medicine, looked at this question for people with diabetes and co-morbid conditions. They found that while many people's priorities lined up fairly well with their doctors', the rate of agreement went down for people in poorer health status, and people who said they had other competing problems that were more pressing than their health. This is not surprising to me -- doctors just aren't very good at diagnosing people's life worlds, as we say, and when those are harder to navigate, it's likely that the doctor will miss what's really going on with the person.

It also turns out that there are some differences generally in doctor and patient priorities. Doctors tend to rank hypertension higher than patients; and, no big surprise, patients are likely to rank symptomatic conditions higher than their doctors do. Hypertension has no symptoms, although it is very dangerous, but people have to struggle every day with pain, breathing difficulties, and cosmetic problems. So this comes out pretty the way I thought it would.

The solution? Doctors need to do a better job of listening, and most important of giving up control of the agenda. They are never going to have much success accomplishing their own goals if they can't serve the patient's goals, let alone if they don't even bother to understand what those are or dismiss them. Unfortunately, this sort of misalignment is very common, because it is embedded in the culture of medicine.

Right now we're thinking about ways of observing and measuring how it is reflected in the interaction process during a visit. I'll keep you posted.

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