For most of the 20th century, the skill of a medical professional was measured discretely. We could put a number, indicative of quality, on things like patients treated, surgeries performed, hours spent in school/residency/fellowships, and research pursued through universities and hospitals. And sure enough, these same types of metrics were reflected in how healthcare was billed: the number of days in the hospital, the number of tests ordered, the number of sterile supplies used, the weight of medications ordered, patients seen per day, and so on.
Medicine in the 21st century hasn’t fully assumed its new character yet. It is fashionable to fantasize about how technology is changing everything, from preventative screenings to patient engagement. The pop-politics that dominate American life give many the courage to speculate on how the government will transform the medical system, both in its delivery and its financial management. But when it comes to assigning qualitative measures to the system, and to the practitioners within it, we may already be able to see what will be most important going forward.
The role of the patient is changing. While patients have always borne some responsibility for making their own treatment work, the importance of adherence is reaching a crescendo. Stakeholders on all sides are looking increasingly toward patients, rather than providers, as key variables in whether medicine will advance and improve, in whether any given program or care model is viable, and whether throwing more tech at a health problem will affect more than wallets.
Adherence in an age of uncertainty
“Doctor’s orders” are being ignored, undermined, and openly questioned by patients with too many competing resources, and too many unacknowledged concerns. They worry about how much treatment will cost, how long it will take, whether they are really getting the best advice, and especially whether they even need to be utilizing the formal medical system in the first place. Patients are persistently distracted from their care plans by a lack of health literacy, by competing concerns with finances and family, and even by technology.
In short, providers have to compete with a lot of challenges to their authority and influence, as well as overcoming a lot of obstacles to having their patients hear, comprehend, and act on medical wisdom. As much blame as society heaps on insurers for narrowing provider networks, or government bureaucrats for disrupting the doctor-patient relationship, the reality of patient compliance is far too complicated and vulnerable for any single stakeholder to solve or shatter independently.
Even more frustrating: Compliance is not the same as engagement. Patients have more reminders of their health concerns than ever, and more ways to address or examine them. Providers can take steps to engage with patients both in and outside the exam room, but that doesn’t automatically translate to improved compliance with care plans.
Enter the machine, exit the exam room
Between the exorbitant costs of medical care in America and the unchartable potential of new technology, the “more is better” approach to healthcare is crumbling. We are looking for value in outcomes rather than inputs, trying to harness technology to manage its risks and realize its benefits. The companies and innovators who drive the development of medical technology are focusing even more sharply on patients than the healthcare system.
For tech companies, patients are all potential consumers, and all people are potential patients. While Congress wrangles with questions of how to leverage the free market to distribute insurance plans and power pharmaceutical innovation, device makers and app developers are busy commoditizing patients with all manner of wearables, health trackers, and DIY resources for the health-conscious. Whether any of this actually helps patients engage with medical professionals remains an open question, but there is no ambiguity about the popularity and the growth trajectory for such consumer-facing tech.
So it is becoming important for providers to influence how patients perceive their unprecedented access to medical information, how they attempt to leverage their self-quantifying wearables and apps, and how much faith they put in the anonymous wisdom of internet-based gurus. Getting a second opinion is almost quaint given the scale and diversity of advice now available. Providers can’t merely add their voices to the crowd of resources; they need strategies to keep patients engaged with their care, and to maintain compliance with the plans developed by their actual caregivers.
Patient-centered care, patient-driven outcomes
Providers aren’t just combating this consumer mindset among patients; amazingly, they are still combating one another. As reimbursement systems shift, populations age, expectations fluctuate, and patient populations swell and migrate, providers are becoming overwhelmed. As states take steps to enable all providers to work at the full scope of their training, arguments persist over just what that even means, and who should be subject to supervision by whom, and on what basis.
The credential shuffle is looking less and less relevant given the rise of value-based care. Doctors are welcome to complain about nurses and PAs encroaching on primary care, but it is looking like those who get the best compliance rates out of patients will reflexively have the best scores in a value-based system.
Nurses, historically, spend more time with patients than any other caregiver or healthcare professional. That would seem to put nurses ahead of their peers in terms of opportunity for and experience with communicating, reaching patients, and finding ways to improve compliance. That would also seem to endorse the idea that nurses should have more autonomy and opportunity to practice at the full scope of their licensure. But the point of this isn’t to say that nurses are better at serving patients, or that the debate of the merits of different providers should be ended; only that, going forward, the providers who achieve patient compliance are the ones who will succeed in the 21st century. That kind of success will come not from MDs or LPNs, but from a combination of interpersonal skills, an ability to leverage technology, an awareness of factors beyond the clinical (especially financial), and most importantly of all, a willingness to collaborate.
Winning the patient lottery
Patient-centered care isn’t just a philosophy, or a cost-management scheme, or a movement to digitally quantify individuals through genetic mapping—although, in various contexts, it is also each of these things. In practice, patient-centered care is a warning to providers: your patients will make or break the success of your research, your care plans, your value-based compensation, and even your professional network.
Some patients will come to their appointments armed with background knowledge, but a curiosity and willingness to listen and learn from their providers; they may utilize online patient portals, wearables, and have an interest in comparing their own metrics to their charts and doctors’ notes; in short, they may be willing to work with providers on mutual terms, to be engaged, compliant, and to follow directions. But many, many more patients will be negatively distracted by gadgetry, intimidated by their providers, or rendered obstinate and skeptical by online contrarians; they may be so inundated with daily emergencies and financial crisis that there is no question of even attempting to fill prescriptions or follow their care plans.
Providers need both the training and the resources to turn encounters with patients into more than a lottery, where outcomes are predetermined based on the openness to adherence patients already possess. Scope of practice, specialization, clinical model, all will quickly come to matter much less than this one feature of the system: improving adherence.