Can we improve quality and reduce costs by improving trust?

July 7th, 2016

July 7, 2016

By Mark McConnell, MD, and James McCormack, Pharm D

Imagine a world where patients trust primary care clinicians, primary care clinicians trust patients, and both trust and use the best available evidence. Such a world improve quality and reduce healthcare costs.

Any read about healthcare policy considers quality and cost. For our purposes, we define quality as an impossible-to-measure blend of what patients want, what primary care clinicians believe should be offered, and what the best available evidence shows to be beneficial. There are many other ways one might define quality, but they tend to focus on metrics that are easily measured. We believe human experience simply cannot be easily measured.

We can improve quality and minimize cost if patients trust their primary care physician.

In many cases patients don’t trust their primary care doctor. There are many reasons for this, including the subtle erosion by the media, advocacy groups, insurers, and others that primary care clinicians are not legitimate authority figures.

We do not take the time, or allowed the time, to engage in conversations of sufficient complexity with patients about the harms and benefits of tests and treatments. Our pay for performance system has created incentives for clinician behavior often contrary to what the patient wants. And we can’t answer many of their questions regarding the harms and benefits of tests and treatments because we have not been trained in translating research findings into layman’s terms, giving patients the needed information for shared, informed decision making. Finally, there are many things in medicine for which we truly don’t have definitive answers or treatments, and a necessary acknowledgement of this does not always inspire trust.

For patients to trust their primary care clinicians, we must:

  • Create incentives for primary care clinicians to spend more time with patients rather than increasing the number of patients seen or the charges per patient. Payers (government and private sector) must accept responsibility for creating these incentives or forfeit identifying themselves as “healthcare” insurers.
  • Admit applicants to medical/professional schools who want to engage in shared informed decision-making, foster the interest they have, and remove educational activities that inhibit that interest. Because payers determine what will be reimbursed, they have a pivotal role to play in operationalizing this dynamic.
  • Create balanced and easy to use “shared decision aids” for tests and treatments. We should have evidence-based decision aids for all common medical conditions.
  • Patients must be convinced their well-being is of greater importance than the financial well-being of payers or clinicians.

We can improve quality and minimize cost if primary care clinicians would trust patients.

Unfortunately, many primary care clinicians have become afraid of patients! Some will tell you that they have had their lives threatened by patients. Almost all will tell you how their livelihood has been threatened by the specter (whether real or imagined) of lawsuits.

We often follow the plethora of guidelines, not necessarily because we believe guidelines represent the best care for individual patients, but because we fear repercussions from patients, colleagues, or payers—which may outweigh our compassion for patients. While clinician decisions on tests and treatments are generally made one patient at a time, represent an opportunity to “get a patient into the numerator” of a metric. This is a dangerous dynamic because if we are perceived as serving metrics rather than individual patients, we may destroy trust.

For primary care doctors to trust their patients, we will need to:

  • Create lasting relationships between both parties that are not mere business transactions.
  • Find ways to remain in one practice for decades in order to build relationships with patients. This cannot happen if we resort to locum tenens and transient primary care clinicians.
  • We need to be able to evaluate and integrate the best available evidence and advise our patients accordingly.

To enhance the doctor-patient relationship, we must also consider removing all financial input from interest groups into research and education. This is idealistic, to be sure, but our governments have enough resources to fund research. In the US, we often support a disingenuous dynamic of universities doing research with government funding, and then turn the results of public efforts into private profit. The public ends up paying twice. Surely we can do better.

It is time we faced the fact that education is flawed because it is often corrupt. However, there are many groups out there trying to tackle the issues of improving healthcare and knowledge translation by focusing on the principles of the best available evidence, clinical expertise and shared decision-making. While no groups have a stranglehold on the truth, groups and individuals that demonstrate a consistent adherence to these principles should play a major role in training and informing healthcare education. Anyone not realizing this is likely blind to the pervasive impact of interest groups on education and how that conflict of interest erodes trust.

Let’s also remove all direct-to-consumer advertising. In the US, we see television ads about monoclonal antibodies that are aimed at patients, who often have no ability to contextualize the information, with the bottom line of “ask your doctor about” said product. But primary care clinicians often do not know much about these products, and time about their queries gobbles up precious office visits.

The essence of decisions about tests and treatments between patients and primary care clinicians requires trustworthy evidence coupled with parties who are willing to, and have the time to, share their values and preferences (patients) and their experience/expertise (primary care clinicians).

Improving quality means reducing waste in tests and treatments, and coming to commonly shared, informed decisions between primary care clinicians and patient values/preferences. We can only do so when patients trust primary care clinicians, primary care clinicians trust patients, and both live in a world where the evidence, on which those decisions are based, can be trusted.

Mark McConnell is a primary care physician in LaCrosse, WI, and James McCormack is a professor of pharmaceutical sciences at the University of British Columbia.