HEALTHCARE
November 7, 2014

Who's at Fault If Treatment Fails?

When a doctor tells a patient to exercise or take a medication and the patient doesn't, who is responsible?

How do you judge a doctor's performance if a patient goes to a doctor and doesn't improve? A joint report just released by several medical associations says that patients' actions (or the lack of them) can matter just as much as doctors' and should be part of the evaluation of treatment. Currently, they are not or are only rarely taken into account.

Medicine more and more involves shared decision-making between doctor and patient, with patients more responsible for their own outcomes. The report suggests this should be reflected when grading a doctor's or hospital's performance.

There's a lot more involved in this approach than assigning blame. It's a shared responsibility. Follow-up matters.

A good example is a man with prostate cancer. There are several different treatment options and plenty of guesswork involved about which treatment is best. And the therapeutic choice is often a personal decision that the patient makes with the help of his doctor.

Yet when it comes to evaluating how effectively a doctor or hospital treat their patients, negatives such as death or illness are often attributed solely to the actions of the doctor or hospital, usually as part of an overall death or sickness rate. For hospitals, part of how Medicare evaluates them, either rewarding or penalizing, is based on patient death rate and the number of readmissions.

But for individual doctors, the blame for a less-than-ideal outcome is often more subtle from a patient or their family. If a doctor writes a prescription that the patient doesn't follow and that action leads to illness or death, is the doctor responsible?

Sometimes people who go off prescription medications have a reason. Side effects from the drug and financial difficulties are two common explanations.

But what about a doctor who prescribes exercise for an overweight patient, and the patient totally ignores the prescription? If the patient happens to die young because of this, should that reflect badly on the doctor?

There's a lot more involved in this approach than assigning blame. It's a shared responsibility. Follow-up matters.

Take a community heart clinic that treats many patients who have high blood pressure. People who are prescribed blood pressure medication often stop taking it after a while. A clinic needs to find effective ways to teach patients not to go off their medication or help them find a more suitable medication.

Patients did not go to medical school — they must have “sufficient support and knowledge to actively participate in their health care,” and that usually comes from the doctors and nurses who treat them.

It's also true that what usually is tracked regarding blood pressure medications is whether or not a doctor prescribes these medications to their patients. Many patients need to take these medications for 20 or 30 years, but it's much easier just to track the initial prescription.

Following decades of patient adherence to medications may prove quite challenging, but that's one of tasks the report says has to be done if we want to see better outcomes — and more accurate assessments of results.

The fact that doctors in the hospital don't wash their hands as often as they should has been cited as a factor in the spread of hospital acquired infections. But hospital patients don't often wash their hands either. How much does each patient contribute to a hospital's infection rate? That's not known right now. But it's almost certain that both contribute and will need to be addressed by programs that seek to lower hospital infection rates.

“The Concepts for Clinician–Patient Shared Accountability in Performance Measures” was released by the American College of Cardiology, American Heart Association, American Association of Cardiovascular and Pulmonary Rehabilitation, American Academy of Family Physicians and the American Nurses Association in collaboration with other professional organizations. It is published in the journal Circulation.
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