Stanley Feld M.D.,FACP,MACE
The complications of chronic diseases account for 80% of the costs of those diseases for the healthcare system.
The role of patients with chronic diseases and their physicians must be clear to both patients and physicians.
President Obama wants to make physicians responsible for the outcome of their care for patients. Physicians have control of making the diagnosis and prescribing treatment.
Physicians do not have control of patients’ adherence to therapy and control of patients’ behavior.
Only patients can be responsible for their behavior. Physicians are managers of a healthcare team. The healthcare team is composed of physician extenders (assistant coaches).
Patients are in the center of the team. Patients live with their disease 24 hours a day. Patients have to learn how to manage the day-to-day fluctuations in the control of their chronic disease.
If the disease is managed well both the acute complications (emergency room visits) and chronic complications (in Diabetes Mellitus heart attacks, blindness, kidney failure and strokes from hypertension) can be avoided.
The cost of care would be markedly reduced if these complications were avoided.
Patients with diabetes need to understand the disease use methods to control their blood sugar, blood pressure and lipid levels.
Physician visits are only a snapshot of what is going on in that patient’s disease process. The information brought to physicians by patients can help physicians, using their clinical judgment, help patients control their disease.
Patients must to be inspired to manage their chronic disease. This requires patients having confidence in their physicians and his assistants.
A good patient/physician relationship can encourage patients to control their chronic disease.
It is hard work for patients to monitor their blood sugar, blood pressure and weight. It is also hard to learn the causes of the fluctuations in their blood sugars and blood pressure.
This idea of mutual trust and confidence between the manager and player are illustrated by something that happened between a teacher and me in high school.
This example is an example of a student/teacher relationship.
It is also an excellent example of the power of an effective patient/physician relationship.
It was a rainy day in the spring of 1953 during my junior year in high school. I was on the high school baseball team. The team could not practice that afternoon because of the weather. The team was sent to the Study Hall for the 8th period.
Ms. W. was one of the 8th period Study Hall teachers. She was my geometry teacher. I thought she was the greatest. I never missed a question in class or on a test. She came over to me that rainy spring day to say hello. She asked how I was doing in trigonometry.
I told her I was not doing well. I can not learn a thing from Mr. B. teaching.
Mr. B. was the chairman of the math department. He taught trig in a very dry way. He was detached. Trig had no meaning to me. He did not teach us to understand the logic of trigonometry and its practical use.
No matter how much I tried to derive meaning from the textbook by myself the material covered was not understandable.
I felt my ability to learn and problem solve was suppressed. Mr. B’s goal was to have us memorize the material.
Mrs. W. asked me which period I had trigonometry and lunch. I told her trig 5th period and lunch 6th period. She said great she taught trig 6th period. She could get me transferred to her class. I could have lunch 5th period.
I was thrilled beyond belief. She also said she hoped I was aware of the departmental quiz being given the next day. I would be required to take the test.
Ms. W said the chances are I would do poorly on the test. She encouraged me to study for it when I got home.
The most amazing thing happened that night when I started studying for the quiz.
All of a sudden I grasped the concepts I could not grasp in Mr. B’s class. Now that I was in Ms. W. class I solved problems I could not solve previously. A difficult textbook became easy to understand.
The next day I went into Ms. W’s trigonometry class, took the test, and got 100%.
I know this has happened to all of us at some time in our life. I know it was the result of my knowing that someone had respect for and confidence in me.
The lesson of Mrs. W. is a powerful lesson. Mrs. W. did enable me to have confidence in my learning ability because of her confidence in me. She empowered me to learn by myself.
If a relationship is positive, with mutual respect and commitment by both physician and patient, patients can learn to control their chronic disease properly.
Chronic diseases such as diabetes frighten patients. This fright makes it difficult to learn how to control their disease to avoid its complications.
Physicians must deal with this through a positive patient/physician relationship. A positive patient physician relationship can make it easier for patients to learn to control their disease.
In practicing endocrinology I developed a patient physician contract to define this physician/patient relationship.
My son Daniel wrote a letter to me about my patient-physician contract that brought tears to my eyes.
I love you. I think everyone should know about your patient-physician contract.
I tell people all the time about your patient-physician contract.
The way you use it to have patients take responsibility for their health and healing.
I’ve adopted this myself in my own health and healing and believe it’s critical since we know ourselves better than anyone else.
The Physician Patient contract as it appeared in Endocrine Practice 2002:8 (Supp 1)
I understand that if I agree to participate in the System of Intensive Diabetes Self-Management, I will be expected to do the following:
1. Dedicate myself to getting my blood glucose level as close to normal as possible by following the instructions of the diabetes self-management team.
2. Regularly visit the clinic for a physical examination, laboratory tests, and nutrition counseling; follow-up visits will be scheduled every 3 months or more frequently if deemed necessary by my physician or other members of my health-care team.
3. Bring a detailed 1-day food record to each follow-up visit, provide necessary nutrition information for me and my dietitian, and adjust my eating habits to meet the nutrition goals established by my dietitian.
4. Use medications as prescribed by my health-care team
5. Monitor my blood glucose levels at home as instructed and brings the results to each follow-up visit.
6. Follow my prescribed exercise plan.
7. Obtain identification as a patient with diabetes, for prompt assistance in case of an emergency.
8. Ask my physician and other members of my health-care team to explain any aspect of my care that I do not entirely understand.
I understand that if I do not monitor myself carefully, there is a risk of hypoglycemia.
I also understand that if I do not strive to normalize my blood glucose, I am at increased risk of developing the complications of diabetes mellitus.
My signature indicates that I have read and understand the above agreement.
I agree to provide the leadership for the diabetes self-management team. Team members will be available to answer your questions and help you self-manage your diabetes. I will continue to encourage you to maintain the best possible control of your diabetes.
__________________________________________ Physician ________________ Date
Obamacare in its attempt to standardize medical care is converting healthcare into a commodity and in the process destroying patient/physician relationships.
The healthcare system cannot be repaired without effective chronic disease management. Chronic disease management will not be effective without effective patient-physician relationships.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. Please have a friend subscribe